LIBRARY 

THE  UNIVERSITY 
OF  CALIFORNIA 

SANTA  BARBARA 


PRESENTED  BY 

Glen   G.    Mosher 


GLEN     G.     MOSHER 


K 


cn>  .    )<\€>& 


THE  ORGANIZATION,  CONSTRUCTION 
AND  MANAGEMENT  OF  HOSPITALS 


WITH  NUMEROUS  PLANS  AND  DETAILS 


BY 
ALBERT  J.  OCHSNER,  B.  S.,  F.  R.  M.  S.,  M.  D. 

8urgeon-in- Chief,  Augustana  Hospital  and  Saint  Mary's  Hospital;  Professor  of 
Clinical  Surgery,  Medical  Department  University  of  Illinois,  Chicago, 

AND 

MEYER  J.  STURM,  B.S.,  ARCHITECT 

CHICAGO 


JTuXIy  JXXustrated 


CHICAGO: 
CLEVELAND  PRESS 

1907 


Copyright  1907 

BY   THE 

CLEVELAND    PRESS 

CHICAGO 


ACKNOWLEDGMENTS. 

We  wish  to  express  our  appreciation  for  valuable  assistance  and  data 
furnished  by  the  following: 
Dr.  S.  S.  Goldwater. 

Prof.  S.  Homer  Woodbridge,  Boston,  Mass,  ventilating. 
Mr.  Win.  Atkinson.   Boston,  Mass..  architect. 
National  Fireproofing  Co.,  Chicago. 
Dr.  Azel  Ames. 

Mr.  I.  J.  Cosgrove.  author  of  -Principles  and  Practice  of  Plumbing." 
Federal  Co.,  plumbing  supplies,  Chicago. 
J.  L.  Mutt  Iron  Works,  plumbing  supplies. 
Cummings  Filter  Co. 
Dr.  John  II.  McCollom. 

Kewanee  Pneumatic  Water  Supply  Co..  Kewanee.  111. 
( leneral  Electric  Co. 

\Y.  P.  Crockett  &  Co..  electric  supplies,  Chicago. 
Mr.  A.  H.  Schroth,  Kellogg- McKay-Cameron  Co..  heating  supplies. 
Acorn  Brass  Mfg.  Co..  ventilation.  Chicago. 

Monash-Younker  Co..  valves,  Chicago. 

Mr.  11.  L.  Calmer,  publisher,  Chicago. 

Sherwin-Williams  Co.,  paints,  Chicago. 

Mr.  Clay  P.  Gooding.  Barrett  Mfg.  Co..  roofing-,  Chicago. 

Dr.    Henry   M.   Hurd. 

The  Illuminating  Engineer,  E.  L.  Elliott,  editor. 

Mr.  Arthur  A.  Ernst,  illuminating  engineer. 

Mr.  Van  Rensselaer  Lansingh,  illuminating  engineer. 

Holophane  Glass  Co.,  New  York. 

Mr.  Daniel  McFarlan  Moore.  Moure  Light  Co. 

Mr.  Horace  Allen. 

( ieneral  Electric  Co. 

Dr.  Renwick  R.  Ross. 

Creamer)   Package  Mfg.  Co.,  refrigeration. 

Troy  Laundry  Machinery  Co..  Chicago. 

Bramhall    Range   Co.,   Chicago. 

Manhattan  Ventilator  ( '.o. 

Handbuch  der  Architektur,  Kraukenhause,     Von     Friedrich     Oswald 

Kuhn. 


TABLE   OF  CONTENTS. 

Introduction    • 1 1 

CHAPTER  I. 
Historical    15 

CHAPTER   II. 
Organization  of  hospitals 27 

CHAPTER  III. 
Officers  and  authority   42 

CHAPTER  IV. 
The  medical  and  surgical  staff   54 

CHAPTER  V. 
Plans  for  the  assignment  of  patients 70 

CHAPTER  VI. 
Discipline  and  rules  governing  staffs 78 

CHAPTER  VII. 
Organization  of  training  schools   92 

CHAPTER  VIII. 

General   construction    106 

CHAPTER  IX. 
Location  of  hospitals  in 

CHAPTER  X. 
Orientation  of  hospital  buildings  in  relation  to  sunlight   1 24 

CHAPTER  XT. 
Masonry    141 

CHAPTER  XII. 
Carpentry   1 50 

CHAPTER   XIII. 

Fireproofing 173 

CHAPTER   XIV. 

Plumbing [98 

CHAPTER  XV. 

Plastering 266 

CHAPTER   XVI. 
Painting   275 


Vlli  TABLE  OF   CONTEXTS 

CHAPTER  XVII. 
Electric  work    282 

CHAPTER  XVIII. 
Ventilation  and  heating   300 

CHAPTER  XIX. 
tron 339 

CHAPTER  XX. 
R<  m  ifing  and  sheet  metal  work 353 

CHAPTER  XXI. 
I A  »ors  and  wainscots 369 

CHAPTER  XXII. 
Illumination   381 

CHAPTER  XXIII. 
Refrigeration   • 411 

CHAPTER  XXIV. 
Equipment  in  construction 422 

CHAPTER  XXV. 
Hospitals  for  towns  of  about  5.000  inhabitants 444 

CHAPTER  XXVI. 
General  consideration  of  hospital  plans   465 

CHAPTER  XXVII. 
General  supplies    52Q 

CHAPTER  XXVIII. 
Hospital  finances   539 


THE 
ORGANIZATION  OF  HOSPITALS 


INTRODUCTION. 

Until  very  recently  the  construction  of  hospitals  was  almost  a 
matter  of  accident,  no  one  having  given  the  subject  any  special  at- 
tention. The  people  furnishing  the  funds  for  its  construction  were 
usually  entirely  innocent  of  any  knowledge  of  the  necessities  in 
the  case.  The  architect  was  chosen,  as  a  rule,  not  because  he  had 
made  a  special  study  of  hospital  construction,  but  because  he  would 
charge  less  for  his  services  than  any  one  else,  or  because  he  had 
more  friends  connected  with  the  management  than  any  of  his  col- 
leagues. He  might  have  specialized  in  the  building  of  residences, 
hotels,  flats,  elevators,  saw-mills,  or  any  other  structures,  and  a 
hospital  planned  by  him  would  naturally  contain  some  character- 
istics of  such  specialty. 

There  are  a  few  notable  exceptions  to  this  rule,  however, 
which  have  resulted  in  giving  to  the  construction  of  hospitals  gen- 
eral tendencies,  which  will  he  discussed  later. 

It  is  of  enormous  importance  to  every  community  contem 
plating  the  erection  of  a  hospital  that  its  institution  shall  supply 
the  following  conditions : 

It  must  supply  the  greatest  amount  of  hospital  care  of  the 
best  quality  to  the  greatest  number  of  patients  at  the  smallest 
possible  expense  as  regards,  (a),  the  construction  of  the  hospital; 
(b),  the  maintenance  of  the  hospital;  (3),  the  expansion  of  the 
institution  as  ^he  demands  for  hospital  beds  increases  in  the  com- 
munity. 

The  difference  in  the  matter  of  original  cost  in  the  construe 
tion  of  hospitals  is  so  extraordinary  that  one  is  able  to  appreciate 
it  only  by  carefully  comparing  individual  instances  and  applying 
the  results  to  the  construction  of  hospitals  in  general. 

Those  best  qualified  to  judge  seem  to  lie  of  the  opinion  that 
every  civilized  community  requires  one  hospital  bed  for  each  one 
hundred  Inhabitants. 

This  ratio,  if  applied  to  the  population  of  this  country,  would 
result  in  the  establishment  of  Dearly  one  million  bospital  beds. 

Comparing  the  construction  of  hospitals  the  following  condi- 
tions will   he  found  to  exist  : 

Institutions  have  been  constructed  so  that  in  one  case  the 
amount  expended   per  patient   per  bed,  may   be  as  high  as   ten 


12  INTRODUCTION 

thousand  dollars,  while  in  another  institution  capable  of  giving 
the  patient  the  same  degree  of  safety,  and  the  same  quality  of  hos- 
pital care,  will  have  cost  not  exceeding  one  thousand  dollars  per 
bed.  Applying  this  to  the  entire  number  of  beds  required  for  the 
proper  hospital  provision  for  this  country  and  the  enormous  dif- 
ference in  the  cost  of  construction  alone  is  nine  billions  of  dollars — 
a  sum  equal  to  the  entire  national  debt  of  this  country  at  the  pres- 
ent time.  Calculating  this  at  an  interest  rate  of  four  per  cent. 
per  annum  we  rind  that  there  would  be  an  annual  waste  of  more 
than  one  million  dollars  per  day.  The  logical  conclusion  from 
these  figures  would  necessarily  be  that  such  useless  extravagance 
must  result  in  an  impossibility  to  provide  a  proper  number  of 
hospital  beds,  or  as  has  happened  in  a  number  of  instances,  after 
the  completion  of  the  structure  there  will  be  no  funds  for  the 
maintenance  of  the  institution.  The  community,  in  other  words, 
will  be  in  the  unfortunate  position  of  the  individual  who  has  ex- 
pended his  entire  fortune  in  the  construction  of  a  mansion,  without 
making  any  provision  for  its  support  when  completed. 

Another  consideration  of  the  subject  would  lead  us  to  equally 
disastrous  results.  A  community  requiring  one  thousand  hospital 
beds  would  expend  the  sum  of  ten  million  dollars  in  the  construc- 
tion of  the  hospital,  were  this  done  on  the  extravagant  basis  of  ten 
thousand  dollars  per  bed.  On  the  other  hand,  were  the  buildings 
constructed  on  the  economical  basis  of  one  thousand  dollars  per 
bed  the  entire  sum  expended  in  producing  the  building,  completed 
for  work,  would  amount  to  one  million  dollars,  leaving  a  surplus  of 
nine  million  dollars  for  maintenance.  Placing  this  at  interest  at 
four  per  cent,  would  result  in  an  annual  income  of  three  hundred 
and  sixty  thousand  dollars,  a  little  less  than  one  thousand  dollars 
per  day,  a  sum  sufficient  to  cover  the  running  expenses  of  such 
an  institution  conducted  honestly  and  economically. 

There  is  a  fundamental  principle  involved  which  makes  it 
possible  for  such  differences  as  these  which  have  just  been  de- 
scribed  to  exist.  The  principle  depends  upon  the  fact  that  in  the 
construction  and  management  of  hospitals  at  the  present  time  it 
rarely  happens  that  the  persons  who  furnish  the  money  for  the  con- 
st ruction  and  maintenance  are  at  the  same  time  actively  employed 
directly  in  the  work.  And  it  is  most  natural  lor  any  person,  no 
matter  how  conscientious  he  may  be,  to  err  in  the  direction  of  pro- 
ducing an  attractive  institution,  rather  than  to  secure  economical 
construction. 

It  is  quite  as  important  to  build  an  institution  with  a  view  to 
economy  in  its  maintenance  after  it  has  been  constructed,  as  it  is 
to   secure  economy    in    the   construction   itself;   because   there  is  a 


INTRODUCTION  L3 

wide  difference  between  the  expense  of  conducting  an  institution 
which  is  conveniently  planned  and  one  which  is  planned  without  re- 
gard to  the  convenience  of  its  management. 

The  average  cost  of  maintaining  a  bed  per  year  is  approxi- 
mately one-third  of  the  cost  of  construction  per  bed;  consequently 
the  amount  expended  for  the  upkeep  of  a  hospital  is  approxi- 
mately the  same  for  every  three  years  of  its  existence  as  the  orig- 
inal cost  of  the  building. 

In  the  management  of  any  other  enterprise  the  tendency  of 
the  present  time  is  to  house  the  enterprise  in  such  a  mannr  that 
it  can  be  carried  on  with  the  greatest  possible  safety,  economy, 
facility  and  convenience. 

In  mercantile  business,  for  instance,  the  building  must  furnish 
an  opportunity  for  accomplishing  the  greatest  possible  amount  of 
business  at  the  smallest  possible  expense.  It  must  be  convenient 
for  those  who  conduct  the  enterprise,  and  attractive  to  those  whose 
patronage  is  sought. 

In  office  buildings  the  tenant  should  have  convenient  quarters 
for  his  work,  combined  with  attractiveness  to  his  clients,  without 
occupying  relatively  too  great  an  amount  of  space  for  his  especial 
business. 

In  manufacturing  enterprises  the  same  principle  is  applied, 
and  so  on  throughout  the  entire  list  of  buildings.  In  each  instance 
the  person  for  whom  the  structure  is  erected  furnishes  the  means, 
either  in  capital  or  in  rentals,  with  which  the  plant  is  constructed. 
It  is  necessary  for  his  continued  existence  in  business  that  the 
building  corresponds  to  the  requirements  in  the  case.  Unless  this 
is  accomplished  his  business  will  suffer  in  competition  with  his 
neighbors;  and  if  his  working  plant  is  entirely  inadequate  this 
fact  alone  will  result  in  his  bankruptcy.  In  other  words,  the  nat- 
ural elements  of  competition  enter  into  the  organization,  const  ruc- 
tion and  management  of  all  of  these  enterprises. 

It  is  a  well  known  fact  that  no  amount  of  capital  could  be 
safely  invested  in  any  business  enterprise  to-day  in  competition 
with  other  similar  enterprises  unless  it  were  established,  built  up 
and  conducted  by  those  familiar  with  the  particular  kind  of  work. 

Every  one  knows  of  prosperous  undertakings  thai  have  heen 
built  up  under  the  leadership  of  a  person  understanding  his  busi- 
ness, and  which  have  gone  to  ruin  at  the  death  of  this  person,  when 
his  heirs,  who  were  not  familiar  with  the  enterprise,  have  assumed 
its  care. 

This  principle  is  constantly  observed  in  the  organization,  con- 
struction and  management  of  hospitals,  and  were  it  not  for  the 
willingness  of  philanthropic  persons  to  foolishly  place  their  wealth 


1-1  INTRODUCTION 

in  the  hands  of  such  incompetents,  those  institutions  must  neces- 
sarily go  on  to  bankruptcy,  precisely  as  is  the  case  in  the  dissolu- 
tions of  private  fortunes  with  which  all  arc  familiar. 

With  the  introduction  of  competition  in  the  conduct  of  hos- 
pitals this  element  must  of  necessity  be  applied  in  the  organiza- 
tion, construction  and  management  of  hospitals  that  hope  to  con- 
tinue for  any  considerable  period  of  time. 

The  important  position  that  hospitals  have  taken  during  the 
past  few  years  has  made  it  worth  while  for  capable  persons  to  make 
hospital  management  their  life-work;  and  this  must  in  time  result 
in  placing  their  management  on  the  same  bases  with  all  other  im- 
portant affairs.  It  is  therefore  becoming  wrorth  while  to  study  the 
subject  of  hospital  organization,  construction  and  management  in 
a  systematic  manner. 


CHAPTER  I. 

HISTORICAL. 

The  word  hospital  has  its  derivation  in  the  Latin  hospitalis 
(adj.)  and  from  the  noun  hospes,  a  host  or  guest.  The  place  in 
which  a  guest  was  received  was  in  Latin  hospitum,  from  which 
was  derived  the  French  hospice.  In  time  the  adjective  became 
used  as  a  noun  and  the  words  hospitalis,  hospitale,  now  hopital 
and  hospitalia,  were  adopted.  The  English  word  hospital  comes 
from  the  old  French  hospitale,  as  do  the  words  hostel  and.  hotel, 
all  originally  derived  from  the  Latin.  The  three  words  hospital, 
hospice  and  hotel,  although  from  the  same  source,  are  used  in 
different  meanings.  The  first,  hospital,  usually  means  establish- 
ments for  temporary  occupation  by  the  sick  and  injured;  the  sec- 
ond, hospice,  a  place  for  permanent  occupation  by  the  poor,  the 
infirm,  the  incurable  or  the  insane;  and  the  last,  hotel,  dwellings 
either  public  or  private,  for  ordinary  occupation. 

Canon  Farrar,  in  his  "Life  of  Christ,"  says,  "Amidst  all  the 
boasted  civilization  of  antiquity  there  existed  no  hospitals,  no 
asylums,  no  penitentiaries."  However  well  this  statement  may 
apply  to  penitentiaries,  it  can  scarcely  be  true  of  hospitals  and 
asylums.  One  need  only  read  pre-christian  history  concerning  hos- 
pitals and  dispensaries,  to  find  authentic  and  interesting  informa- 
tion regarding  the  curing  of  the  sick,  the  instruments  and  medi- 
cines used,  and  the  places  provided  for  housing  them  in  sickness. 
If  these  houses  or  refuges  were  not  called  hospitals,  it  is  only 
because  the  word  as  applied  to  its  present  meaning  was  not  then 
in  use.  Certainly  the  work  organized  and  the  work  accomplished 
in  those  days  was  worthy  the  respect  and  consideration  of  sci- 
entists even  in  this  over-scientific,  overworked  twentieth  century. 

There  has  been,  and  there  is  now,  much  discussion  and  inquiry 
as  to  the  origin  of  hospitals,  Jews  and  Christians  alike  contending 
for  the  honor  of  having  first  given  them  to  mankind.  For  the 
word  only  should  they  be  given  priority;  in  worthy  deeds  the 
work  had  long  been  accomplished  before  them  by  the  Romans  and 
the  Hindus. 

Hospitals  are  simply  the  development  of  the  dispensary  used 
in  ancient  times  by  medical  officers  appointed  and  paid  by  the 


1(5  HISTORICAL 

state.  This  room  or  dispensary  was  used  by  the  medical  officers 
in  which  to  see  their  patients  and  dispense  their  drugs.  This 
eventually  developed  into  the  hospital  ward,  where  patients  could 
be  more  carefully  attended,  and  be  under  observation  by  the  med- 
ical officers.  4kIt  is  therefore  in  the  medical  officer,  appointed  and 
paid  by  the  state,  that  we  find  the  earliest  germ  and  first  idea  of 
the  vast  network  of  hospitals  which  have  spread  over  the  civil- 
ized countries  of  the  world." 

In  the  eleventh  century  B.  C.  there  was  a  college  of  physicians 
in  Egypt,  who  received  public  pay,  and  were  ruled  by  law  as  to 
the  extent  and  nature  of  their  practice.  At  Athens  in  the  fifth 
and  sixth  centuries  B.  C.  there  existed  physicians  and  dispen- 
saries; mention  is  also  made  of  one  hospital.  The  physicians 
were  elected  and  paid  by  the  citizens. 

In  the  fourth  century  B.  C.  an  edict  in  India  by  King  Asoka 
commanded  the  establishment  of  hospitals  throughout  his  domin- 
ions, and  there  is  direct  proof  that  these  hospitals  were  in  ex- 
istence and  flourishing  in  the  seventh  century  A.  D.  We  read  in 
Homer  of  army  surgeons,  consequently  they  are  of  remote  an- 
tiquity. The  first  military  hospital  of  which  we  have  any  definite 
record  was  established  during  the  reign  of  Hadrian,  in  Rome.  117- 
138  A.  D.  The  ancient  Mexicans  had  hospitals  for  their  wounded 
and  disabled  soldiers,  and  for  the  care  of  the  sick  of  all  classes. 
Asylums  for  the  insane  were  first  discovered  among  the  Moham- 
medans. 

That  the  ''medical  administration"  was  made  to  include  both 
man  and  beast  is  a  direct  indication  of  the  wisdom  of  the  govern- 
ment in  caring  for  its  subjects.  We  quote  from  the  edicts  of  the 
establishment  of  a  system  during  the  time  of  Alexander  the  Great, 
300  B.  C:  "That  wells  and  trees  and  caravanseries  were  to  be 
erected  in  the  public  highways  for  the  use  of  travelers;  and  that 
the  sick  and  wounded  were  to  be  carefully  attended  to  by  the  erec- 
tion of  medical  houses  or  hospitals,  and  depots  of  medicine  for 
the  sick  of  man  and  animals."  '  (History  of  Medicine,  1857.) 

These  are  the  first  hospitals  of  which  we  find  any  distinct 
record.  They  were  provided  with  instruments  and  medicines  of 
all  kinds  made  from  mineral  and  vegetable  or  herb  drugs.  "And 
skillful  physicians  were  appointed  to  administer  them  at  the  ex- 
pense of  the  state."  It  is  also  stated  that  the  sick  were  pro- 
vided with  food  "according  to  their  experience  of  what  is  right." 
From  these  significant  details  we  may  conclude  that  medical 
knowledge  among  the  ancient  Asiatics  was  based  upon  humane 
ami  practical  principles,  with  no  element  of  superstition,  hyp- 
notism and  fraud  that  came  later  in  connection  with  this  work. 


EISTORICAIi 


17 


Evidence  is  conflicting  concerning  the  reign  and  the  death  of 
Gautama  Buddha,  but  it  can  be  safely  estimated  that  both  of  these 
events  occurred  as  early  as  the  fourth  century  B.  ('.  We  find 
record  of  his  having  appointed  physicians,  "one  For  every  ten 
villages";  and  he  also  built  asylums  for  the  sick,  the  destitute,  and 
for  the  cripples.  His  son  Upatisso  built  hospitals  for  the  blind 
and  for  pregnant  women.  Just  here  it  seems  fitting,  in  further 
proof  of  the  pre-christian  origin  of  hospitals,  to  quote  from  the 
Westminster  Review,  1877. 

"Thus  we  see  that  the  glory  of  Christianity  does  not  lie  in 
having  originated  the  idea  of  hospitals,  but  in  having  seized  it 
like  the  runners  the  torch  in  the  ancient  games,  and  carried  it  for- 
ward with  brighter  flame  and  more  intense  enthusiasm.  The  fame 
of  Fabiola  and  St.  Basil  lias  been  immortalized  by  St.  Jerome  and 
the  Gregorys;  the  edict  of  Asoka  is  graven  with  a  pen  of  iron  in 
the  rock  and  a  living  witness  to  the  noble  thoughts  of  his  kingly 
mind;  the  "House  of  Sorrow,"  which  was  built  within  the  ancient 
rath  that  exists  to  this  day,  speaks  of  the  tenderness  of  the  Prince— 
Macha ;  but  no  trace  remains  of  the  names  and  titles  of  "the  men 
and  women  who  built  the  solitary  hospital  on  the  seashore  in  the 
Poraes,  who  founded  the  house  of  separation  for  the  lepers  in 
Judea,  and  the  home  for  disabled  soldiers  in  Mexico,  or  of  those 
more  illustrious  who,  in  ancient  Egypt,  conceived  the  idea  of  the 
physicians  paid  by  the  state  to  tend  the  poor.  Their  names  may 
be  forgotten,  but  their  deeds  are  immortal ;  they  have  joined 

"That  choir  invisible 
Whose  music  is  the  gladness  of  the  world." 

After  the  introduction  of  Christianity  we  have  reference,  flrst. 
to  the  "Pool  of  Bethesda,"  31  A.  [).,  where  shelters  were  erected 
for  the  sick  and  the  cripples  who  came  to  drink  the  water  which 
was  said  to  possess  miraculous  healing  powers. 

In  the  years  370-80  A.  D..  Valens,  in  Ca?sarea,  Fabiola,  in 
Rome,  built  hospitals  and  almshouses  for  the  sick  and  destitute 
After  this  came  the  infirmaria  of  the  monasteries.  In  the  course 
of  time  these  infirmaries  developed  into  separate  buildings,  with 
special  appropriations  for  their  maintenance. 

In  the  ninth  century,  at  Sienna,  the  Knights  of  St.  John,  of 
Jerusalem,  built  hospitals  for  pilgrims  and  attended  them  when 
they  were  sick. 

About  the  year  1530  Jolmde  Dies,  a  Portuguese  of  the  order 
of  the  "Brother  Hospitallers."  converted  his  home,  a  deserted 
shed,  into  a  hospital;  and  in  time  he  came  in  possession  of  a  large 
building,  where  he  and  many  other  pious  men  cared  for  the  sick 


18  HISTORICAL 

and  unfortunate.  In  this  way  the  first  hospital  of  the  Order  of 
Charity  was  founded. 

It  will  be  interesting  to  quote  here  from  the  Encyclopedia 
Britannica,  1881  :  "About  the  earliest  distinct  record  of  the  build- 
ing of  a  hospital  in  England  is  in  the  life  of  Lanf ranee,  archbishop 
of  Canterbury,  who,  in  1080,  founded  two,  one  for  leprosy  and  one 
for  ordinary  diseases.  The  former  is  referred  to  in  the  Vie  de  St. 
Thomas  le  Martyr,  a  work  of  the  twelfth  century.  The  establish- 
ments for  the  sick  remained  in  the  hands  of  the  clergy  until  the 
Reformation,  when  some  of  the  monasteries  and  church  proper- 
ties were  appropriated,  and  set  apart  for  the  use  of  the  sick.  Of 
these  the  most  noted  instances  were  St.  Bartholomew's,  at  Smith- 
field,  St.  Thomas'  in  the  Borough,  Bethlehem  or  Bedlam,  Bride- 
well, and  Christ's  Hospital,  which  were  long  known  as  the  'Five 
Royal  Hospitals.'  " 

From  this  time  until  the  beginning  of  the  eighteenth  century 
the  information  and  records  concerning  hospital  building  is  of  a 
nature  too  vague  to  be  interesting.  It  was  in  the  eighteenth  cen- 
tury that  the  "great  movement"  in  hospital  building  took  place. 
The  following  table  from  Dr.  Steels'  paper  "On  the  Mortality  of 
Hospitals"  (Encyclopedia  Britannica,  1881)  gives  a  list  of  the 
chief  institutions  founded  during  that  period  in  England. 

Date  of  Date  of  Date  of 

foundn-  founda-  founda- 

London.  tion.      Provincial.        tion.      Irish.  tion. 

Westminster   ..  .1710  York    1710      Dublin. 

Guy's    1723  Salisbury   1716  Jervis  St 1726 

St.  George's   .  .  .1733  Cambridge 1719  Steevens's   1733 

London  " 1740  Bristol 1735  Mercer's     1734 

Middlesex    174.5  Edinburgh   1736  Meath   1756 

Special  Hospitals.    Windsor 1736  House  of   Indus- 

The  British   Ly-  Aberdeen   1739      try 1774 

Lng-iu  Ilospt.   1749 Northampton    ..1743      Special  (Dublin). 

<  il  v    of    London  Exeter    1745  The  Rotunda  Ly- 

Lying-in   1750  Worcester- 1745      ing-in    1745 

Queen  Charl'te's         Newcastle    1751  The  Lock 1754 

L\  iii-in   1752  Manchester   . .  .  .1753  The     Westmore- 

Smallpox    1716  <  ihester     1755      land  Lock 1755 

L.»,k,  female  .  .  .1745  Leeds    1767  Cork    1720 

Lock   male        .  .1747  Stafford 1769  Limerick    1759 

Oxford    .1770  Belfast    1797 

Leicester    1771 

Norwich   1771 

I  >umfries   1775 

Hereford 1776 

Birmingham    .  . .  1778 
Montrose 1780 


HISTORICAL  19 

Date  of 

founda- 

Provincial.        tion. 

Nottingham  .  . .  .1782 
( lanterbury    ....  1.793 

Glasgow  1794 

Dundee  1795 

Stafford   1797 

According  to  Guttstart  tlie  increase  of  hospitals  in  Germany 
from  1876  to  1900  were  3,300  in  number,  and  according-  to  the 
Medical  Commission  of  Germany  there  were  3,000  hospitals  with 
140,000  beds,  and  in  1900  there  were  6,300  hospitals  with  370,000 
beds,  an  increase  of  250  per  cent  in  the  number  of  beds  in  a  quarter 
of  a  century.  In  Prussia  alone  statistics  show  that  from  1,502 
hospitals  with  a  total  of  73,000  beds  in  1876,  there  was  a  total  of 
2,040  hospitals  with  110,000  beds  in  1S-S5,  and  the  enormous  total 
of  3,900  hospitals  with  214,000  beds  in  1900.  In  less  than  twenty- 
five  years  in  this  small. state  alone,  the  number  of  beds  had  been 
tripled. 

In  this  country,  also,  great  attention  is  paid  to  the  subject  of 
hospitals  and  hospital  building.  The  increasing  interest,  and  the 
increasing  demand,  has  influenced  thoughtful,  skillful  men  to 
make  the  study  of  hospital  construction  a  life  work',  and  in  con-" 
quence  the  present  century  must  undoubtedly  mark  a  new  era  in 
all  matters  pertaining  to  the  organization,  construction  and  man- 
agement of  hospitals.  The  same  vast  changes  that  have  been 
wrought  in  other  industries  must  come  into  this  field  as  well,  and 
the  last  quarter  of  the  last  century  has  introduced  many  now  con- 
ditions and  elements.  The  most  important  changes  indicated  are 
due  to  our  knowledge  of  the  life  history  of  various  pathogenic 
bacteria,  and  an  appreciation  of  the  manner  of  their  transmission 
from  one  person  to  another.-  For  many  centuries  it  has  been 
known  that  contagion,  infection  and  inoculation  were  conditions 
that  must  be  considered  in  connection  with  hospital  care  of  pa- 
tients, but  the  actual  manner  in  which  these  conditions  were  ac- 
complished were  unknown  until  the  work  of  Louis  Pasteur  made 
it  possible  for  Joseph  Lister  t«»  applj  the  principle  of  infection 
directly  to  surgery,  and  (his  in  Inrn  opened  the  field  to  other 
scientists  until  the  entire  subject  has  become  a  part  of  the  edu- 
cation of  all  who  are  interested  in  hospital  work.  This  principle 
of  infection  has  influenced  the  construction,  and  given  rise  to  the 
consideration  of  hygienic  principles  in  all  inhabited  buildings,  but 
more  particularly  in  hospital  buildings.  The  influence  of  damp- 
ness, dust  and  absence  of  sunlight  has  become  an  importanl  factor 


20  HISTORICAL 

to  be  studied  in  connection  with  hospitals.  In  the  old  records  we 
find  ninny  traces  to  indicate  that  these  tacts  were  understood  and 
appreciated  thousands  of  years  ago,  and  it  is  interesting  to  specu- 
late as  to  whether  these  facts  were  based  upon  scientific  principles 
as  applied  to  things  in  ancient  times,  or  whether  these  really  sim- 
ple truths  were  observed  as  a  matter  of  self -protection,  or  of 
instinct. 

There  arc  many  factors  to  influence  the  growth  of  hospitals 
and  make  concentration  a  natural  result. 

The  growth  of  enormous  cities  has  produced  conditions  which 
demand  public  and  semi-public  care  for  a  great  portion  of  the 
population. 

The  element  of  safe,  cheap  and  rapid  transportation  of  pa- 
tients by  railroad  train,  electric  street  railways,  modern  ambu- 
lances, and  later,  perhaps,  the  automobile  ambulance,  will  further 
influence  this  field. 

The  possibility  of  constructing  many-storied  buildings  safely 
at  a  relatively  small  cost,  with  perfect  protection  against  fire,  has 
its  effect. 

The  introduction  of  hygienic  plumbing  is  of  great  importance. 

The  use  of  the  elevator  and  the  dumb  waiter  added  another 
feature  to  the  construction,  especially  in  large  cities. 

The  introduction  of  the  trained  nurse  has  affected  every  phase 
of  hospital  organization,  construction  and  management. 

The  element  of  competition,  perhaps  more  than  any  other 
factor,  is  influencing  the  growth  and  the  construction  of  hospitals. 

The  development  of  preventive  medicine  and     the     changes 
which  are  in  progress  in  the  sociological  conditions  in  this  count n 
must  add  further  features  to  the  future  history  of  matters  per- 
taining to  hospitals. 

All  of  these  elements  have  been  gaining  in  importance  from 
year  to  year,  and  they  are  also  becoming  more  definite  in  their 
influence. 

As  stated  elsewhere,  the  prevailing  idea  is  that  there  should 
be  one  hospital  bed  for  every  hundred  inhabitants  in  this  country. 
It  is  easy  t<>  calculate  from  this  that  the  subject  of  hospital  build- 
ing has  passed  from  the  stage  of  a  necessary  evil,  through  the  ex- 
perimental stage,  until  we  now  must  strive  to  have  the  best  facili- 
ties in  all  respects  in  these  buildings. 

Accepting,  then,  the  evidence  of  the  growth  and  development 
of  hospitals,  and  appreciating  the  necessity  for  their  existence, 
there  remains  the  question  of  the  kinds  of  hospitals  that  should  be 
constructed  and  approved  of. 

It  is  acknowledged  that  there  is  an  absolute  demand  for  hos~ 


HISTORICAL  -\ 

pitals  in  ease  of  epidemics,  in  order  to  keep  the  afflicted  separate 
from  those  not  so  unfortunate;  in  many  instances  these  hospitals 
hove  apparently  been  the  means  of  arresting  the  spread  of  disease, 
and  thus  preventing  extensive  epidemics. 

There  are  general  hospitals  to  which  cases  of  all  kinds  are 
admitted,  while  in  others  certain  classes  of  paiients  are  excluded. 

Under  the  head  special  hospitals  are  classed: 

Hospitals  for  the  insane. 

Hospitals  for  neurasthenics. 

Hospitals  for  contagious  diseases. 

Hospitals  for  tuberculosis. 

Hospitals  for  epidemics. 

Hospitals  for  obstetrical  patients. 

Hospitals  for  surgical  patients. 

Hospitals  for  children's  diseases. 

Military  hospitals. 

Naval  hospitals. 

While  Naval  and  Military  hospitals  are  classed  under  the  head 
of  special  hospitals,  they  are,  as  regards  management  at  least,  dis- 
tinctly different  from  the  others.  The  following  extract  from 
Encyclopedia  Britannica,  1890,  gives  a  brief  outline  of  these  hos- 
pitals past  and  present : 

"These  are  provided  in  all  civilized  countries  for  the  care  of 
sailors  and  soldiers  of  state.  The  two  great  English  hospitals  of 
Greenwich  and  Chelsea  were  founded  as  asylums  for  disabled  and 
superannuated  sailors  and  soldiers,  but  the  former  is  given  up 
for  that  purpose,  although  a  part  is  appropriated  as  a  hospital  for 
sick  merchant  seamen  of  all  nations.  The  chief  naval  hospitals 
are  those  of  Hasler,  Chatham,  and  Plymouth.  Hasler  is  the  larg- 
est hospital  in  the  country,  having  been  originally  intended  for 
2,000  sick,  and  even  now,  with  increased  allowance  of  space  per 
bed,  accommodating  1,500  patients.  There  are  also  hospitals  in 
most  of  the  principal  naval  stations  abroad,  such  as  Malta,  .Ja- 
maica, Halifax,  Hongkong,  etc.  The  principal  military  hospitals 
are  the  Royal  Victoria  Hospital  a*  Nolly  (the  invaliding  hospital 
of  the  army  and  the  locality  of  1  he  army  medical  school),  the  Hei 
bert  Hospital  at  Woolwich,  the  Cambridge  Hospital  at  Udershotl 
and  numerous  others  at  the  principal  stations.  die  cubic  space 
allotted  by  regulation  is  1,200  cubic  feel  at  home  and  L,500  to 
2,000  cubic  feet  in  the  tropics,  per  \u^\.  Formerly  every  regiment 
of  cavalry  and  infantry,  and  each  battery  or  troop  of  artillery,  had 
its  own  hospital,  but  this  plan  is  now  given  up,  and  station  hos- 
pitals with  a  fixed  staff  are  being  arranged  at  the  chief  centers  of 
military  districts.      In  both  the  army  and  the  navv  the  regulation.- 


HISTORICAL 


place  the  administration  and  command  of  hospitals  in  the  hands 
of  the  respective  medical  departments;  in  the  army  this  as  yet  is 
only  partially  carried  out,  but  it  has  been  accomplished  in  the  navy 
with  the  advantage  of  both  efficiency  and  economy.  In  time  of  war 
general  hospitals  are  established  at  the  base  of  operations,  whilst 
field  hospitals  move  with  the  troops  as  the  campaign  pro- 
gresses. ' ' 

"In  France  there  have  long  been  hospitals  established  for  the 
navy,  snch  as  those  at  Eochefort,  Toulon,  Brest,  etc.,  as  well  as 
schools  of  instruction  for  medical  officers.  The  chief  military  hos- 
pital is  at  the  Val  de  Grace  at  Paris,  formerly  a  convent ;  it  is  there 
that  the  medical  school  for  the  army  is  located,  Larue  hospitals  are 
also  established  in  all  the  great  stations.  Great  attention  to  military 
hospitals  is  also  paid  in  Germany,  Austria  and  other  countries  of 
Europe.  In  most  of  them  the  administration  is  in  the  hands 
of  the  medical  department,  except  in  France,  where  the  intendence 
still  holds  the  reins,  much  to  the  disadvantage  of  efficiency  and 
good  working." 

"In  the  United  States  of  America  the  army  is  small  and  chiefly 
employed  on  frontier  duties,  so  that  the  hospitals  are  all  what  are 
(ailed  post  hospitals,  and  as  a  rule  are.  wooden  huts  or  temporary 
structures,  built  to  last  ten  years,  and  to  hold  12  to  14  beds.  There 
are,  however,  two  permanent  hospitals,  one  for  cadets  it  West 
Point,  and  the  other,  the  LV.rnes  Hospital,  at  the  Soldiers'  Home 
near  Washington.  All  the  arrangements  are  under  the  army 
medical  department.  The  navy  and  mercantile  marine  were  long 
amalgamated  in  America,  so  far  as  hospital  arrangements  went." 
The  Marine  Hospital  Service  was  formed  in  1798,  and  the  navy 
was  not  separated  from  it  until  1811,  although  it  was  not  for  some 
years  after  that  special  naval  hospitals  were  built.  In  connection 
with  marine  hospital  service,  hospitals  have  been  established  at  a 
great  number  of  ports,  both  sea,  river  and  lake.  Op  to  1870  each 
of  these  hospitals  had  its  own  organization,  but  since  that  time  a 
regular  service  has  been  established  under  a  supervising  surgeon- 
general.  A  tax  of  40  cents  a  month  is  levied  for  the  service  upon 
all  seamen  or  members  whatsoever  of  a  ship's  company.  One  of 
the  finest  hospitals  is  the  Mercantile  Marine  Hospital  at  Chicago, 
a  pavilion  building  of  several  stories,  and  of  considerable  archi- 
tectural pretentions.  But  in  America,  as  in  Europe,  the  tendency 
has  latterly  been  to  abandon  such  monumental  hospitals,  and  to 
construct  single-storied  pavilions  on  the  hut  or  "barrack"  prin- 
ciple the  word  barrack  being  employed  in  this  sense  as  equivalent 
to  the  French  baraque.  a  wooden  hut.  Accordingly  the  new 
marine  hospital  at  San  Francisco  has  been  thus  constructed,  three 


HISTORICAL  L'o 

one-storied  pavilions  of  California  redwood  radiating  from  the 
outside  of  a  curved  corridor,  from  the  ends  and  inner  center  of 
which  project  the  administrative  blocks.  The  cosl  is  about  $600 
per  bed,  whereas  the  average  cost  of  the  older  ones  was  fully  seven 
times  that  amount,  with  the  drawback  thai  in  course  of  time  they 
became  extremely  unhealthy,  and  showed  all  the  evils  of  hos- 
pitalism." 

A  brief  notice  will  be  added  here  of  the  history  of  hospitals, 
particularly  with  reference  to  the  pavilion  system : 

"It  is  in  France  that  we  must  look  for  the  commencement  of 
that  system,  although  it  has  been  carried  out  with  even  greater 
success  in  other  countries.  Its  origin  may  be  traced  to  the  discus- 
sions which  arose  from  time  to  time  as  to  the  advisability  of  re- 
constructing the  Hotel-Dieu  at  Paris.  So  long  ago  as  the  seven- 
teenth century  Desgodets,  architect  to  Louis  XIV.,  presented  a 
plan  for  reconstructing  the  hospital  in  'rayons.'  But  it  was  after 
the  fire  that  took  place  in  1772  that  question  was  taken  up  with 
real  interest.  In  1773  it  was  proposed  to  transfer  the  hospital  to 
the  plain  of  Grenelle,  and  in  1774  M.  Petit  proposed  a  radiating 
building  of  four  stories  at  the  base  of  the  hill  of  Belleville  (prob- 
ably at  no  great  distance  from  the  existing  hospital  of  Menil- 
monant).  M.  ie  Roi  presented  a  plan  for  a  hospital  at  Chaillot, 
consisting  of  long,  single-storied  pavilions,  arranged  alternately, 
with  the  roof  open  at  intervals,  each  patient  to  be  screened  off  by 
partitions.  Finally  the  committee  of  the  Academic  des  Sciences 
reported  favorably  in  1788  on  a  proposal  of  M.  Poyet's  to  con- 
struct a  hospital  on  the  lie  des  Cygnes  (between  Grenelle  and 
Passy),  consisting  of  isolated  pavilions  radiating  from  a  central 
rotunda,  the  hospital  to  hold  5,000  patients,  each  pavilion  to  be 
110  feet  long,  by  24  feet  broad  and  14  to  15  feet  high,  to  contain 
34  to  30  patients,  and  to  have  windows  to  the  ceiling.  These  pro- 
portions would  give  77  to  so  square  feet  of  floor  space.  to  0'..  to 
6%  feet  wall  space,  ami  1,080  to  1,200  cubic  feet  of  total  space,  an 
immense  advance  upon  then  existing  arrangements.  The  devo- 
lution put  a  stop  to  those  projects,  and  halt'  a  century  elapsed 
before  a  pavilion  building,  as  now  understood,  was  actually  con 
structed.  Curiously  enough,  revolution  again  stepped  in  to  arrest 
the  movement,  for  the  firsl  building  of  Hie  kind,  the  Hopital 
Louis-Philippe,  was  begun  in  i'w^  last  years  of  that  monarch's 
reign,  and  suspended  in  consequence  of  the  revolution  oi  Feb- 
ruary, 1848.  Some  years  Inter  it  was  completed  and  renamed 
Lariboisiere,  from  the  name  of  the  benefactress  whose  munificence 
helped  to  bring  it  to  a  successful  conclusion." 

"The  new  hospital  at  Menilmontant,  in  thenortheasl  of  Paris, 


24  HISTOETCAL 

is  also  a  pavilion  one,  differing  somewhat  in  detail,  but  of  great 
size,  each  pavilion  having  numerous  stories.  The  military  hospital 
Vincennes  is  a  good  specimen  of  modern  construction.  A  small 
experimental  pavilion  built  on  the  suggestions  of  Dr.  Tarnier  in 
the  garden  of  Maternite  in  Paris,  merits  notice.  It  consists  of 
two  stories,  each  containing  four  wards,  these  wards  being  each 
for  one  parturient  woman.  The  kitchen,  office,  etc.  are  in  the  cen- 
ter, hut  the  only  access  to  these  wards  is  by  the  verandah  direct 
from  the  open  air.  The  walls,  floor  and  ceilings  are  non-absorbent, 
and  there  is  a  space  of  56  cubic  meters,  or  nearly  2,000  cubic  feet, 
for  each  inmate." 

"The  plans  of  M.  Toilet  ought  not  to  be  passed  unnoticed. 
In  addition  to  the  ordinary  principles  of  pavilion  construction,  he 
insists  upon  the  ogival  or  Gothic  form  of  architecture,  which  he 
thinks  was  adopted  in  the  Middle  Ages,  as  mUch  for  sanitary  as 
for  architectural  reasons." 

The  first  pavilion  hospital  in  England  was  the  Blackbourn 
Infirmary,  built  rather  more  than  twenty  years  ago.  The  pavilions 
there  are  at  right  angles  to  the  center  corridor,  and  are  alternate; 
a  similar  arrangement  Ls  followed  out  at  the  Children's  Hospital 
at  Pendlebury,  near  Manchester.  St.  Thomas'  at  Westminster 
Bridge  consists  of  a  row  of  parallel  pavilions  united  by  a  cor- 
ridor at  one  end.  A  plan  practically  identical  was  proposed  for  a 
now  hospital  at  Valetta  (Malta),  but  this  building,  though  fre- 
quently referred  to  in  hooks,  has  never  been  constructed.  The 
Herbert  hospital  at  Woolwich  consists  of  parallel  pavilions  jutting 
(»ut  from  the  sides  of  a  center  corridor  at  right  angles:  although 
it  is  now  nearly  twenty  years  old,  it  is  still  one  of  the  best  ex- 
amples of  a  pavilion  hospital.  The  latest  pavilion  hospital  is  the 
New  Royal  Infirmary  at  Edinburgh. 

In  Germany  the  Priedrichsheim  Hospital  at  Berlin  is  one  of 
the  host  specimens  of  a  pavilion  building.  The  pavilions  are  Kin 
feet  apart,  six  two  storied,  and  four  one  storied,  with  isolation 
wards  and  the  necessary  administration  buildings.  The  hut  hos- 
pital erected  during  the  late  war  at  Tempelhof,  near  the  same  city, 
was  a  good  example  of  how  the  pavilion  system  may  be  indefinitely 
extended,  the  huts  being  placed  in  echelon  in  wide  zigzag  lines." 

"The  earliest  American  hospital  of  any  size  was  the  Pennsyl- 
vania Eospital  of  Philadelphia,  which  was  begun  in  1755,  under 
the  auspices  of  Dr.  Thomas  Bond  and  Benjamin  Franklin,  and 
finished  in  L805.  It  was  also  in  Philadelphia  that  the  first  pavilion 
hospital  of  a  permanent  character  was  erected,  the  corner  stone 
being  laid  in  L860;  in  it  the  pavilions  are  parallel,  two  stories,  be- 
side- the  basemeni  and  attics.    The  space  allowed  is  ample,  but  the 


HISTORICAL  25 

wards  are  too  wide,  nearly  31  feet.  Ln  New  York  there  is  a  la 
amount  of  hospital  accommodation — about  6,000  beds,  or  aboul  1 
in  1,500  of  the  population.  The  New  York  Hospital  new  pavilion 
gives  111'  square  feet  of  floor  space  and  1,800  cubic  feet  of  total 
space.  The  Roosevelt  Hospital  has  somewhat  the  same  dimen- 
sions, but  with  a  much  greater  space  for  surgical  patients.  <  me 
peculiarity  of  arrangement  in  that  building  is  that  the  closets  are 
not  at  the  ends  of  the  wards  as  usual,  hut  in  the  center,  grouped 
around  a  central  shaft  which  extends  through  all  the  stories,  cel- 
lar ami  basement.  In  this  the  water  and  steam  pipes  are  placed, 
as  also  the  foul  linen  shafts;  the  closets  are  cleaned  by  a  steam 
jet.    This  plan  does  not  seem  very  commendable. 

The  Massachusetts  General  Hospital  at  Boston  is  the  oldest 
in  America,  except  the  Pennsylvania  Hospital.  Since  1ST-  four 
new  pavilions  have  been  built  en  peculiar  plans;  two  are  square, 
one  containing  one  large  ward  for  twenty  patients,  and  the  ofher 
divided  into  small  rooms  of  two  heds  each,  giving  each  aboul  !'7 
feet  of  floor  space,  and  1,500  to  1,850  feet  of  total  space;  the 
other  two  are  oblong,  divided  into  rows  of  single  rooms,  with  ■» 
dividing  corridor,  something  like  an  arrangement  of  prison  cell-. 
The  floor  space  is  about  the  same,  with  less  height. 

The  Johns  Hopkins  Hospital  at  Baltimore  will  be  memorable 
for  the  care  bestowed  upon  the  consideration  of  its  plans.  The 
one  finally  adopted  is  on  the  pavilion  principle,  scattered  over  a 
wide  space  of  ground." 

This  brings  us  to  a  new  era  in  hospital  construction  in  this 
country.  This  era  began  with  that  notable  collection  of  essays  on 
hospital  construction  published  in  1875  ("Hospital  Construction 
and  Organization,"  "The  Johns  Hopkins  Hospital").  During 
the  last  quarter  of  the  last  century  this  work  was  used  universally 
as  a  guide  by  all  architects  in  this  country,  as  well  as  by  all  Boards 
of  Trustees  who  were  painstaking  enough  to  personally  study  the 
subject  of  hospital  construction  and  organization,  ln  England  and 
on  the  continent  one  finds  frequent  references  in  the  hospital 
literature  to  this  excellent  work,  which  considered  the  subject 
broadly  and  completely,  from  the  standpoint  of  conditions  pi'" 
vailing  ;it  that  time. 

In  Europe,  the  Berlin  Hospital  nt  Friedrichsheim  has  been 
mentioned  before  as  an  example  of  this  pavilion  form  of  construc- 
tion. The  Hamburg  Hospital  at  Eppendorf  is  probably  the  most 
perfect  sample  of  this  system  on  the  continent.     For  practical  pur 

poses  we  may  refer  to  these  hospitals  a--  the  models  after  which 

most  hospitals  of  the  latter  pari  <>f  the  past  century  were  planned. 

The  idea  of  the  cottage  hospital  was,  however,  carried  out    in 


26  HISTORICAL 

detail  just  one  hundred  and  fifty  years  ago  by  an  English  engineer 
by  the  name  of  Rovehead,  who  planned  a  complete  cottage  hos- 
pital at  Stone  House,  near  Portsmouth.  England,  for  the  care  of 
seamen.  This  plan  was  so  complete  that  there  is  scarcely  a  hos- 
pital built  to-day  on  the  cottage  plan  which  can  compare  in  the 
detail  of  the  idea  with  this  hospital. 

A  review  of  tlie  excellent  work  of  Sir  Henry  C.  Burdett, 
"Hospitals  and  Asylums  of  the  World,"  1893,  gives  the  plans  of 
all  the  important  hospitals  which  were  constructed  before  the  close 
of  its  publication,  and  virtually  all  of  these  contain  the  same  essen- 
tials in  their  construction.  When  we  bear  in  mind  that  during  the 
pasi  thirty  years  everything  in  our  theories  concerning  infection, 
contagion  and  hygiene  has  changed,  and  that  scientifically  proven 
facts  have  taken  the  place  of  theories,  would  it  not  seem  strange 
should  we  still  adhere  to  the  same  essentials  in  hospital  construc- 
tion? Since  the  beginning  of  the  present  century  it  has  become 
more  and  more  apparent  that  the  principles  laid  down  in  "The 
Johns  Hopkins  Hospital,"  1875,  can  no  longer  be  used  .as  a  basis 
for  hospital  construction  at  the  present  time.  As  a  result  of  the 
changes  there  is  a  strong  tendency  toward  the  construction  of  com- 
pact, many-storied  buildings,  especially  in  the  larger  cities  of  this 
.country. 

Thus  the  history  of  our  subject  teaches  that  civilization  has 
experienced  changes  in  this  field  as  in  every  other  form  of  devel- 
opment.  We  find  a  faint  tradition  of  a  high  form  of  development 
in  what  may  be  called  the  pre-historic  time;  then  we  enter  the 
dark  ages  with  all  their  superstitions  and  misconceptions;  then 
came  the  slow  but  constant  development  which  resulted  in  the  rec- 
ognition of  fundamental  principles  of  hygiene  upon  which  at  the 
present  time  are  based  our  ideals  in  Hospital  Construction.  With 
all  possible  modern  facilities  as  regards  location,  ventilating,  heat- 
ing, lighting  and  plumbing,  the  sick  can  be  placed  under  hygienic 
conditions  which  correspond  to  those  to  be  desired  by  persons  in 
health. 


CHAPTER  II. 

ORGANIZATION    OF    HOSPITALS. 

The  organization  of  hospitals  must  necessarily  vary  with  the 
conditions  under  which  the  institutions  are  to  exist. 

The  first  step  must  be  the  formation  of  a  board  of  directors, 
governors,  or  trustees,  no  matter  whether  the  institution  be  under 
the  control  of  a  political  organization  like  the  State,  County  or  the 
City,  or  whether  it  be  controlled  by  a  Philanthropic  Society,  Church 
Organization,  Medical  School,  Corporation  of  Physicians,  or  by 
Private  Corporations  such  as  Transportation  Companies,  Manu- 
facturing Companies,  Mining  Enterprises,  or  by  a  Fraternal  Or- 
ganization of  Wage  Earners. 

We  shall  consider  each  one  of  the  various  forms  of  control 
separately,  and  shall  give  that  form  which  at  the  present  moment 
seems  to  contain  the  greatest  number  of  virtues,  and  the  smallest 
number  of  defects.  It  is  not  unlikely  that  future  experience  will 
show  in  many  instances  that  many  forms  of  control  now  in  vogue 
in  a  given  class  of  hospitals  must  be  superseded  by  entirely  new 
methods,  because  with  the  development  of  institutions,  conditions 
must  change  in  this  as  in  every  other  human  endeavor. 

The  object  in  the  present  effort  is  to  give  that  which  experi- 
ence has  shown  to  be  the  best  organization  up  to  the  present  time. 

HOSPITALS  CONTROLLED  BY  POLITICAL  BODIES,  SUCH 

AS  BOARDS  OF  TRUSTEES,  UNDER   STATE, 

COUNTY.  Oil  CITY  GOVERNMENT. 

These  institutions  arc  usually  developed  for  the  purpose  of 
providing  for  the  poor  who  can  be  treated  more  perfectly,  and  with 
greater  economy,  than  it  each  patient  were  cared  for  as  an  Indi- 
vidual charity. 

In  most  communities  there  arc  such  institutions  also  provided 
for  the  treatment  of  special  diseases,  like  insanity,  epilepsy  and 
imbecility.  In  the  organization  of  such  hospitals  a  fairly  definite 
system  has  been  established,  the  usefulness  of  which  depends  en- 
tirely upon  the  honesty  of  purpose  of  the  political  organization  in 

power. 

In  the  organization   of  the  gov. ■ruing  body   of  these   institu- 


28  ORGANIZATION    OF    HOSPITALS 

tions,  the  same  as  in  the  other  forms  mentioned,  there  are  certain 
qualities  required.  The  trustees  must  have  experience  in  this 
field.  If  they  arc  appointed  because  of  their  experience,  and  be- 
cause they  have  worked,  faithfully,  intelligently,  and  honestly  in 
hospital  work  for  years:  if  they  have  studied  institutional  work 
carefully,  and  it*  their  other  duties  in  Life  are  such  that  they  can 
give  attention  to  this  specialty,  then,  with  their  position  as  trus- 
tees relatively  permanent,  it  is  reasonable  to  look  for  a  satisfactory 
result. 

If  on  the  other  hand,  these  trustees  are  selected  by  political 
powers  in  control,  as  a  remuneration  for  some  political  services 
rendered  the  party,  no  care  being-  taken  to  select  men  well  qualified 
to  fill  the  position,  then  the  organization  must  necessarily  be  ex- 
ceedingly bad. 

To  make  matters  worse,  such  boards  of  trustees  appointed  as 
a  result  of  what  is  usually  termed  the  "spoils  system"  in  politics 
can  maintain  their  position  only  so  long  as  the  political  party  re- 
mains in  power  and  there  must  of  necessity  therefore  be  frequent 
changes  in  the  membership  of  such  boards. 

If  the  same  system  is  applied  also  to  the  officers  of  the  insti- 
tution, to  the  nurses  and  servants,  in  other  words,  if  there  is  no 
plan  of  civil  service  employed  in  any  part  of  the  hospital,  then 
the  organization  can  be  said  to  be  as  bad  as  possible. 

It  has  been  demonstrated,  however,  that  by  the  introduction 
of  civil  service  in  hospitals  under  political  control,  the  organiza- 
tion can  be  made  very  nearly  perfect  provided  the  trustees  are 
selected  because  of  their  qualifications,  and  according  to  a  system 
which  prevents  frequent  changes. 

NUMBEB  OF  TRUSTEES. 

It  is  important  that  the  number  of  trustees  be  relatively  small 

because  this  will  enable  the  community  to  employ  capable  | pie, 

to  give  them  a  reasonable  compensation  for  their  services,  and 
require  of  them  a  sufficient  amount  of  time  to  correspond  with  the 
requirements  of  the  institution  under  control. 

In  some  States  these  trustees  compose  the  Board  of  Control 
which  manages  all  of  the  public  institutions:  prisons,  insane  asy- 
lums, hospitals.  State  orphanages,  institutions  for  the  blind,  for 
the  deaf  and  dumb,  for  imbeciles,  and  for  epileptics. 

A  few  of  these  Boards  are  composed  of  men  of  very  great 
learning,  splendid  practical  ability  and  undoubted  morals,  who 
have  made  institutional  work  a  life  study,  precisely  as  one  would 
make  educational  or  professional  work  a  life  duty.  In  such  in- 
stances the  results  have  been  amazingly  good. 


ORGANIZATION    OF    HOSPITALS  _'.* 

The  number  of  trustees  should  not  be  loss  than  three,  nor  more 
than  fifteen.  The  plan  which  has  been  followed  in  many  hospitals, 
of  having  a  very  large  Board  of  Trustees  with  the  hope  of  being 
able  to  enlist  in  this  manner  the  interest  of  a  large  number  of  per- 
sons, who  would  themselves  contribute  freel\  to  the  support  of 
the  institution,  and  who  would  at  the  same  time  secure  support 
from  other  persons,  has  failed  to  bring  the  highest  satisfaction. 
In  so  large  a  Board,  there  is  never  enough  for  each  individual  to 
do  to  keep  him  permanently  interested,  and  where  so  many  persons 
have  to  be  consulted  in  the  matter  of  management,  progress  is 
almost  impossible. 

When  one  remembers  that  most  of  the  business  enterprises, 
such  as  commercial  undertakings,  manufacturing  concerns,  rail- 
roads or  banks,  have  a  relatively  small  number  of  Directors,  it 
becomes  plain  that,  in  order  to  succeed  and  prosper,  a  hospital 
should  also  have  a  relatively  small  number  of  Directors. 

In  public  institutions  under  political  patronage  it  would 
hardly  be  safe  to  have  less  than  three  or,  better,  five  Directors,  be- 
cause of  the  danger  of  forming  combinations  for  personal  gain. 

Taking  three  as  the  number  to  be  appointed  in  a  State  insti- 
tution by  the  Governor,  in  a  city  institution  by  the  Mayor,  or  in 
a  county  institution,  preferably  by  the  Judge  of  the  Probate  Court, 
it  is  wise  to  have  one  member  appointed  so  as  to  retire  at  the  end 
of  each  three  years,  so  that  the  term  of  office  of  one  will  be  for 
nine  years.  Of  the  original  Board  to  be  appointed,  one  would 
serve  for  three  years,  one  for  six,  and  the  third  for  nine  years. 
In  case  the  number  were  five,  then  one  should  be  appointed  every 
second  year,  making  the  term  of  service  ten  years.  In  case  the 
number  be  greater  than  seven  it  is  probably  best  to  appoint  one 
each  year,  making  the  term  of  service  equal  in  years  to  the  number 
of  Directors. 

In  some  institutions  a  further  precaution  has  been  taken  by 
making  it  necessary  for  the  Board  to  contain  members  from  dif- 
ferent political  parties.  In  case  the  Board  consists  of  five  mem- 
bers, not  more  than  three  may  be  appointed  from  the  political 
party  in  power.  In  case  it  consists  of  seven  members,  not  more 
than  four,  and  so  on  throughout  the  scries  of  numbers.  There 
is  a  distinct  advantage  in  this  because  in  case  of  a  change  in  politi- 
cal power  the  new  executive  may  (ill  the  next  vacancy  from  his 
own  party,  and  in  case  of  a  vacancy  from  other  causes  the  com- 
position of  the  Board  will  not  be  seriously  disturbed  by  the  change 
in  administration,  and  there  will  exist  no  temptation  to  the  new 
appointive  power  to  force  resignation  by  unfair  means,  in  order 


30  ORGANIZATION    OF    HOSPITALS 

that  lie  may  introduce  members  of  his  own  political  party,  for  his 
own  political  reasons,  because  he  would  be  compelled  to  again  ap- 
point members  of  the  opposing  party  to  replace  those  whose  resig- 
nation he  had  forced. 

The  permanency  of  the  office  will  give  these  Trustees  a  suf- 
ficient security  so  that  they  can  plan  improvements  in  the  service 
for  several  years  in  advance. 

Many  of  the  men  in  this  service  have  made  a  ca  .refill  study  of 
their  subject,  and  of  the  institutions  in  other  States.  As  a  result 
of  this  system  the  institutions  in  such  communities  are  conducted 
with  great  economy  and  efficiency.  The  staffs  of  these  hospitals, 
the  employes,  the  training  school  for  nurses,  are  all  splendidly 
organized.  The  supplies  are  remarkable  for  their  excellence,  at 
the  same  time  they  are  bought  at  a  reasonable  price,  and  the 
amount  of  waste  is  reduced  to  a  minimum,  both  as  regards  work 
and  material. 

Such  a  Board  is  able  to  select  its  employes  for  permanent 
service  because  of  their  ability  to  do  the  particular  work  entrusted 
to  them  in  the  best  possible  manner. 

So  far  as  known  the  employes  in  these  institutions  have  a 
permanent  service  for  a  period  of  four  years,  during  this  time 
they  can  be  removed  only  for  bad  behavior,  or  neglect  of  duty.  At 
the  end  of  this  time  their  service  terminates  unless  they  are  re- 
appointed. This  provision  seems  to  be  a  wise  one,  because  it 
implies  the  necessity  of  continued  efficiency.  A  person  does  not 
maintain  his  position  simply  because  lie  has  secured  it  and  because 
he  does  nothing  bad  enough  to  warrant  his  removal,  hut  he  must 
perform  his  duties  sufficiently  well  to  make  him  more  desirable 
to  the  institution  than  his  competitor  who  has  filled  all  the  require- 
ments by  passing  examinations  establishing  his  practical  qualifica- 
tions and  by  which  he  is  on  the  available  list  for  the  particular 
work  performed  by  the  employe  in  question. 

There  is  a  feature  in  this  system  for  the  appointment  of  a 
Board  of  Trustees  which  must  not'be  overlooked.  The  advantage 
to  the  person  who  has  the  power  of  appointing — the  Governor, 
Mayor  or  Judge  of  Probate  (Kurt — cannot  possibly  be  great  if 
he  makes  the  appointment  from  selfish  motives,  because  he  can 
never  hope  during  his  official  existence  to  obtain  actual  control  of 
the  Board  so  that  he  could  utilize  it  for  his  personal  advantage, 
even  if  he  were  so  inclined.  A  bad  appointmenl  would  cause  so 
much  opposition  from  so  many  sides,  that  the  slight  amount  of 
personal  gain  would  not  count  in  comparison  with  the  loss  in 
popularity;  and  this  fact  makes  the  appointmenl  of  Trustees  more 
likely  to  result  in  a  competent  Board  than  the  plan  of  popular 


ORGANIZATION    OF   HOSPITALS  31 

election.  (This  of  course  is  not  the  case  -where  the  entire  Board 
is  appointed  by  the  official  in  charge  at  a  given  time.) 

If  with  the  election  of  every  Governor,  or  Mayor,  or  Judge  of 
Probate  Court,  or  President  of  County  Commissioners,  the  entire 
Board  is  replaced  by  a  Board  appointed  by  the  new  incumbent, 
then  this  Board  may  be  selected  to  serve  a  political  "boss,"  and 
then  the  institution  must  necessarily  suffer  as  a  result  of  this  bad 
system.  Some  of  the  worst  managed  hospitals  and  asylums  in 
the  world  are  under  Trustees  appointed  in  this  manner.  The 
extravagance  in  construction  and  management  in  some  of  these 
institutions  is  beyond  conception;  and  the  care  of  patients  in  in- 
stitutions whose  Trustees  are  appointed  in  this  manner  suffer 
from  all  directions  because  of  the  fact  that  the  incompetence  of 
the  Trustees,  added  to  the  selfish  motives  underlying  their  exist- 
ence, is  carried  through  the  entire  system.  The  bills  paid  for 
construction  and  for  management  would  purchase  the  best,  but 
the  poorest  is  delivered;  the  same  is  true  regarding  the  bedding 
and  food,  and  applies  to  the  service,  to  the  personnel  of  the  medi- 
cal staff,  to  the  capacity  of  the  officers  of  the  institution,  to  the 
nurses,  and  even  to  the  servants,  whose  number  is  usually  abnor- 
mally large  in  order  to  provide  profitable  positions  for  supporters 
of  the  political  machine,  and  their  incompetence,  indolence,  and 
irresponsibility  are  correspondingly  great. 

In  the  great  cities  of  this  country  the  possibility  of  the  con- 
tinued existence  of  a  system  organized  in  this  manner  is  easily 
explained.  Those  who  profit  by  this  vile  system  are  in  a  position 
of  authority,  and  so  long  as  the  system  is  to  their  personal  ad- 
vantage, they  are  not  likely  to  institute  changes.  Even  men  of 
most  excellent  qualities,  and  a  high  moral  standing,  will  serve  in 
some  capacity  connected  with  these  institutions,  and  as  a  matter 
of  policy  those  in  power  usually  secure  a  sufficient  number  of  such 
men  to  give  the  institution  a  certain  semblance  of  standing. 

The  two  sides  that  suffer  as  a  result  of  this  procedure  are 
those  who  pay  the  taxes,  who  furnish  the  funds  for  the  institu- 
tion, on  the  one  side,  and  the  patients  on  the  other  side,  who  do 
not  receive  the  care  that  they  would  if  the  money  were  honestly 
expended,  and  who  are  not  in  a  position  to  objecl  to  such  a  system. 

The  tax-payer  knows  practically  nothing  concerning  the  con- 
ditions, he  is  interested  in  his  own  affairs,  and  the  patienl  is  glad 
to  get  what  he  can.  so  long  as  lie  gets  it  i'vov  of  cost.  Patients  who 
would  be  entitled  to  the  service  to  be  obtained  in  these  public  in- 
stitutions, but  who  are  too  intelligent  to  submit  to  such  abuses,  in 
the  large  cities  receive  treatment  in  other  hospitals  conducted  by 
Philanthropic  Societies  or  Church  Organizations. 


'.V2  ORGANIZATION    OF    HOSPITALS 

It  is  quite  a  different  matter  in  the  State  insane  asylums, 
and  State  institutions  for  the  education  of  imbeciles,  and  for  epi- 
leptics,  because  in  these  all  except  the  very  wealthiest  members  of 
the  population  of  the  State  receive  treatment. 

Fortunately  the  spoils  system  is  not  so  common  in  these  in- 
stitutions as  it  is  in  connection  with  City  and  County  hospitals. 
This  is  probably  due  to  the  fact  that  a  larger  proportion  of  the 
intelligent  pari  of  the  population  is  directly  interested  in  the  in- 
dividual coming  under  such  care.  The  matter  of  extravagance  is 
controlled  by  the  necessity  of  the  Board  to  make  a  favorable  rec- 
ord. There  is  a  possibility  of  paying  for  better  supplies  than  are 
received,  but  in  these  institutions  such  discrepancies  cannot  be 
great. 

In  studying  the  conditions  in  State  institutions  for  the  past 
quarter  of  a  century,  one  must  necessarily  have  observed  an 
enormous  change  in  the  conditions  mentioned,  and  it  only  remains 
for  the  intelligent  portion  of  the  population  to  comprehend  the 
principle  involved,  both  as  regards  the  cost  of  conduct  under  the 
spoils  system,  as  compared  with  the  reasonable  system  such  as  has 
been  described,  and  as  regards  the  natural  result  of  entirely  elim- 
inating the  possibility  of  having  such  institutions  conducted  under 
the  spoils  system. 

■In  the  organization  then,  of  State,  Comity  or  City  hospitals 
of  all  kinds  the  following  plan  seems  to  be  the  most  reasonable, 
and  the  most  certain  to  produce  the  best  possible  results. 

The  Board  of  Trustees  should  consist  of  five  members  in  the 
primary  organization,  one  of  these  should  be  appointed  for  ten 
years,  the  second  for  eight  years,  the  third  for  six  years,  the  fourth 
for  four  years,  the  fifth  for  two  years;  after  that,  in  case  of  State 
institutions,  the  Governor  should  appoint  one  member  every  sec- 
ond year;  in  case  of  a  City  institution,  the  Mayor  should  have  this 
appointing  power;  in  case  of  the  Comity,  it  should  be  left  to  the 
Judge  of  Probate  Court,  or  to  the  President  of  the  Board  of 
County  Commissioners.  In  each  instance  it  would  be  well  to  pre- 
vent the  appointment  of  more  than  three  members  from  the  politi- 
cal party  of  the  person  in  power. 

This  Board  should  make  a  financial  report  to  the  Governor, 
or  the  Mayor,  or  the  Judge  of  Probate,  or  the  President  of  the 
Board  of  County  Commissioners,  accordingly.  It  should  also 
make,  at  stated  intervals,  requisition  .for  the  necessary  funds  for 
the  ensuing  year,  this  requisition  to  be  acted  upon  by  the  legisla- 
tive body  of  the  corporation  indicated,  whether  State,  City  or 
County. 

The  Board  of  Trustees  having  been  elected  the  organization 


ORGANIZATION    OF    imsi'i  I  \l.s  ,.', 

is  completed  by  the  election  of  a  President,  Vice  President,  Sec- 
retary and  Treasurer,  and  the  appointmenl  of  ;i  committee  of 
three  persons  for  each  importanl  division  of  the  labor  involved. 

The  work  can  be  so  divided  thai  each  member  is  the  Chairman 
of  one  of  the  important  committees,  and  thai  two  of  the  other 
members  serve  as  associates. 

The  Chairman  can  thus  become  thoroughly  familiar  with  his 
portion  of  the  administration,  and  every  member  can  be  kepi 
posted  concerning  every  detail  of  the  entire  work. 

The  important  Committees  are  on  Finance,  on  Buildings  and 
Grounds,  on  Supplies,  and  the  Committee  on  Employes. 

From  this  point  on  the  management  must  correspond  with 
the  management  of  hospitals  organized  by  non-political  bodies; 
which  we  shall  consider  at  this  point. 

ORGANIZATION    OF    HOSPITALS    BY    PHILANTHROPIC 

SOCIETIES. 

In  cities  of  moderate  size  in  which  the  political  conditions 
seem  unfavorable  for  the  organization  of  city  hospitals,  and  in 
which  no  particular  church  seems  strong  enough  to  have  such  an 
institution  of  its  own,  it  is  often  best  to  organize  a  philanthropic 
society  for  the  purpose  of  establishing  a  hospital. 

This  supplies  the  community  with  hospital  facilities,  and  at 
the  same  time  leaves  the  institution  in  the  hands  of  the  best  citi- 
zens of  the  community. 

The  principal  drawback  in  the  fulfillment  of  such  a  plan  lies 
in  the  fact  that  it  requires  an  entirely  new  organization  for  which 
experience  has  not  as  yet  granted  very  satisfactory  precedents. 

Were  it  possible  to  maintain  the  interest  of  a  large  number  of 
these  good  people,  such  an  institution  must  necessarily  become 
very  prosperous  because  of  the  character  of  its  supporter-.. 

When  we  remember,  however,  that  each  one  of  these  supporl 
ers  considers  the  institution  simply  of  incidental  importance,  and 
that  his  chief  energies  arc  directed  toward  his  own  individual  en 
terprises,  then  it  becomes  plain  why,  as  a  matter  of  experience, 
such  institutions  have  not  been  as  prosperous  as  they  deserve  to  be. 

It  is  in  this  form  that  the  error  of  a  very  Large  Board  of 
Trustees  has  usually  been  made,  with  the  result  that  oone  of  the 
members  of  the  Board,  with  the  exception  of  a  few.  ever  become 
thoroughly  familiar  with  the  work-,  and  thai  consequently  the  in- 
stitution is  likely  to  be  left  in  the  hands  of  those  least  competent 
to  manage  matters  of  such  importance.  FVequentrj  the  whole 
conduct  of  the  hospital  ultimately  falls  into  the  hands  <>f  ladies 


34  ORGANIZATION    OF    HOSPITALS 

auxiliary  boards,  or  it  is  permitted  to  drift  along  with  practically 
no  management  until  something  happens  sufficiently  bad  to  tem- 
porarily attract  the  attention  of  those  whose  constant  care  is 
needed  to  build  up  the  institution  to  a  degree  of  usefulness  one 
could  reasonably  expect  of  it. 

There  is  a  remedy  for  this  difficulty  which  has  been  practised 
with  great  success.  In  every  community  there  are  business  men 
of  excellent  judgment,  energy," reliability  and  experience,  who  have 
retired  from  active  commercial  pursuits,  either  entirely  or  to  such 
an  extenl  as  to  leave  almost  their  entire  time  free  for  rest,  or  for 
such  things  as  they  can  find  to  do  without  exposing  themselves  to 
any  groat  degree  of  wear  and  tear.  A  Board  of  Trustees  com- 
posed of  such  men,  wherever  it  has  been  tried,  lias  insured  the  in- 
troduction of  tried  business  principles  into  the  organization  and 
management  of  hospital  institutions. 

The  character  and  recognized  judgment  of  these  men,  serves 
to  assure  those  who  contribute  toward  the  support  of  the  under- 
taking, that  the  money  is  wisely  expended,  and  vouchsafes  a  de- 
gree of  stability  which  can  hardly  be  secured  if  the  institution 
is  in  the  hands  either  of  impractical  philanthropists,  or  business 
men  who  are  so  completely  occupied  with  other  concerns  that  they 
can  give  little  or  ho  time,  and  no  continued  thought,  to  the  hos- 
pital. 

The  selection  of  the  members  of  such  Boards  must  depend 
largely  upon  the  manner  in  which  the  organization  is  constituted, 
but  experience  lias  shown  that  no  matter  how  the  organization  is 
constituted,  there  are  some  principles  which  must  be  introduced 
and  maintained  in  order  to  make  the  undertaking  eminently  suc- 
cessful. Of  these  the  most  important  is  the  one-  already  mentioned, 
viz.,  every  member  of  the  Board  of  Trustees  should  possess  busi- 
ness capacity.  This  will  become  more  and  more  necessary  in  the 
future  because  of  the  natural  introduction  of  the  element  of  com- 
petition. 

So  long  as  hospitals  are  few  even  those  managed  without 
business  capacity  may  continue  to  exist,  and  even  prosper  to  a 
certain  degree.  This  however  will  no  longer  be  possible  as  soon 
as  there  is  active  competition. 

The  next  quality  which  each  member  of  the  Board  of  Trus- 
tees should  possess  is  an  interest  in  the  development  of  the  insti- 
tution. 

Wherever  Trustees  are  chosen  because  of  their  prominence, 
either  in  business  <>r  in  social  affairs,  with  the  hope  that  this  alone 
may  bring  prosperity  to  the  institution,  one  is  certain  to  find  dis- 
appointment. 


ORGANIZATION'    (»!•'     LlOSCll  ALS  .»•> 

Hospitals  cannot  grow  spontaneously;  those  Intrusted  with 
their  conduct  must  furnish  the  impetus  to  their  development,  pre- 
cisely the  same  as  though  it  were  in  other  enterprises.  Aside 
from  this  it  is  necessary  that  the  Trustees  be  willing  to  contribute 
a  considerable  amount  of  time  practically  every  day  to  this  work. 
There  is  an  endless  amount  of  labor  connected  with  the  various 
details,  which  can  be  left  to  subordinates  in  a  general  way,  bul 
the  supervision  of  which  musl  be  in  the  hand-  of  the  Trustees, 
and  unless  this  is  done  the  development  will  be  weak  at  some  point, 
and  progress  must  necessarily  be  obstructed. 

It  is  plain  that  in  these  institutions,  as  well  as  those  under 
political  control,  it  is  important  that  the  management  should  not 
fall  into  the  hands  of  dishonest,  selfish  persons,  who  use  the  cloak 
of  charity  as  a  means  of  advancing  their  own  personal  interests. 

In  this  class  of  institutions  this  has  perhaps  happened  -  > 
rarely  as  to  not  merit  particular  consideration,  but  with  the  growth 
and  development  of  hospitals  everywhere  conducted  by  philan- 
thropic societies  there  is  a  sufficient  possibility  of  danger  from 
this  side  to  make  it  important  that  those  interested  in  suck  Lnsti 
tutions  should  hear  it  in  mind. 

Taking,  then,  for  granted  that  the  Board  of  Trustees  has  been 
selected,  composed  of  not  more  than  fifteen  men  with  acknowledged 
business  capacity,  and  of  high  moral  standing,  with  an  interest  in 
the  development  of  the  institution,  and  with  a  willingness  to  give 
a  considerable  amount  of  time  to  the  work,  and  an  ability  to  do 
this  without  neglecting  their  other  duties  in  life,  the  purpose  is 
properly  started  in  its  organization. 

Were  one  to  apply  all  of  these  conditions  to  any  other  design, 
the  same  number  of  men.  with  the  same  qualifications  and  interest 
in  the  organization  and  development  of  that  with  which  they  were 
quite  entirely  unfamiliar,  one  would  scarcely  expect  very  satis- 
factory  results;  and  still  in  every  community  in  which  a  hospital  is 
originally  started,  this  state  of  things  must  necessarily   exist. 

One  would  naturally  look  to  the  physicians  in  the  comraunit) 
for  advice  in  this  relation,  because  they  are  directly  interested, 
and  because  during  their  studies  they  have  aaturallj  come  in  con- 
tact at  least  nominally  with  hospitals  connected  with  medical 
schools.  In  (\uv  course  there  will  he  valuable  help  in  the  organiza- 
tion and  development  from  this  direction,  hut  in  the  past  mosl 
physicians  have  gone  into  practice  without  having  had  any  official 
connection  or  training,  having  simply  seen  the  pafients  and  ob 
served  their  treatment  without  the  opportunity  of  learning  the 
minor  working  of  t  he  hospital  institutions  visited  more  or  less  r<  g 
ularly. 


36  ORGANIZATION    OF    HOSPITALS 

At  the  present  time  an  increasing  proportion  of  yonng  grad- 
aates  in  medicine  look  forward  to  the  time  when  they  will  be 
officially  connected  with  the  staff  of  sonic  hospital,  seeking  the 
position  of  residents  in  hospitals  directly  after  graduating;  and 

while  in  this  position  they  not  only  perform  their  duties  as  assist- 
ants, i»nt  they  also  learn  all  they  can  concerning  the  management 
of  the  institutions  in  which  they  happen  to  he  located.  It  i^  from 
these  men  that  Boards  of  Trustees  will  in  time  learn  much  con- 
cerning hospital  management;  but  it  is  only  from  lung  continued 
experience  that  they  can  hope  to  attain  perfection  in  this,  as  in 
every  other  sphere  of  work.  This  fact  in  itself  makes  it  of  the 
greatesl  importance  that  each  member  of  the  Board  of  Trustees 
shall  have  a  service  sufficiently  long-  to  make  it  worth  while  to  give 
the  time  necessary  for  becoming  thoroughly  familiar  with  his 
duties.  This  can  be  best  accomplished  in  the  following  manner: 
Take  for  instance  a  Board  composed  of  fifteen  members.  The 
service  of  each  member  composing  the  original  board,  should  vary 
from  one  to  fifteen  years.  Each  successive  year  the  place  of  the 
member  whose  term  expires  should  lie  filled  by  a  new  member 
whose  term  of  service  should  be  fifteen  years. 

In  ease  the  number  of  Trustees  be  less  than  teu  and  more 
than  five,  a  new  member  should  be  elected  every  second  year.  In 
ease  the  number  be  five,  which  is  the  smallest  reasonable  number 
of  Trustees  for  an  institution  of  this  kind,  the  service  of  the 
original  members  should  be  for  periods  of  three,  six.  nine,  twelve 
and  fifteen  years,  and  after  this  election,  a  new  member  every  three 
years  for  a  period  of  fifteen  years. 

There  are  many  other  distinct  advantages  aside  from  the 
element  of  permanency.  The  system  provides  that  there  will 
always  be  a  large  majority  of  Trustees  who  have  been  on  duty 
a  sufficient  length  of  time  to  be  familiar  with  the  conduct  of  the 
institution,  and  each  new  member  will  have  gained  much  expe- 
rience before  it  will  be  possible  for  him  to  introduce  foolish  and 
untried  methods  which  are  ruinous  to  the  progress  and  prosperity 
of  any  undertaking,  and  which  are  more  likely  to  be  foisted  into 
the  conduct  of  an  institution  in  which  the  funds  are  not  supplied 
directly  by  the  management. 

It  is  Datura]  to  hesitate  before  introducing  new,  untried 
methods  in  the  conduct  of  business  enterprises,  in  which  failure 
would  result  in  considerable  personal  financial  loss.  This  is  not 
always  true,  however,  in  institutions  in  which  there  i>  no  possi- 
bility of  personal  loss. 

Furthermore,  the  element  of  permanency  encourages  the  am- 
bition of  actually  accomplishing  worthy    philanthropic    ends,    in 


ORGANIZATION    OF    HOSPITALS  -b 

other  words,  which  makes  it  worth  while  to  plan  relatively  greal 
things  for  the  future. 

Xo  matter  what  the  Dumber  of  Trustees  may  be  H  is  well  to 
have  any  vacancy  which  may  occur  temporarily,  filled  by  the  re- 
maining members  of  the  Board,  because  in  this  way,  all  the  com- 
mittees may  he  kept  constantly  tilled,  and  it  will  not  be  necessary 
to  have  special  elections  at  irregular  times. 

The  vacancies  from  any  cause  should  he  tilled  permanently 
for  the  remaining  period  of  service  of  the  Trustees  whose  vacancy 
is  to  he  tilled  at  the  next  regular  election. 

It  is  important  that  these  institutions  he  conducted  in  a  mm 
personal  manner.  The  service  should  he  according  t<>  the  most 
advanced  form  of  civil  service  method.  Too  often  people  who  have 
been  unable  to  earn  a  livelihood  in  any  other  occupation,  but  who 
have  been  able  to  secure  the  friendship  of  some  member  of  the 
Board  of  Trustees  have  been  employed.  In  this  way  it  frequently 
happens  that  the  work  that  could  be  done  by  one  competenl  per- 
son, to  the  advantage  of  the  institution,  is  very  poorly  done  by  two 
or  three,  or  more,  incompetents. 

It  is  obvious  that  no  business  or  manufacturing  enterprise 
conducted  on  this  plan,  could  exist  for  any  great  period  of  time 
in  competition  with  one  properly  conducted. 

CHURCH    HOSPITALS. 

What  has  been  said  of  the  organization  of  hospitals  under  the 
control  of  philanthropic  societies  can  be  said  with  equal  truth  of 
institutions  under  the  control  of  religious  denominations.  These 
institutions  are,  however,  possible  only  in  the  larger  cities,  be 
cause  the  membership  of  any  individual  denomination  in  a  small 
town  or  city  is  scarcely  sufficient  to  support  an  independent  insti- 
tution, and  the  fact  of  a  hospital  in  these  towns  being  denomina- 
tional is  likely  to  result  in  Opposition  from  the  various  other  de- 
nominations. Moreover,  hospitals  in  great  centers  belonging  to 
the  various  churches  usually  attract  attention  and  aid  from 
the  churches  of  the  same  denomination  in  the  smaller  communi 
ties,  and  from  these  churches  secure  a  considerable  portion  of 
their  membership.  For  this  reason  it  is  probably  better  to  make 
the  hospitals  in  all  the  smaller  towns  entirely  non  denominational. 

It  is  well  to  distribute  the  member-  of  the  Board  ^\'  Trustees 
in  these  denominational  institutions  among  the  various  churches 
of  the  community.  If  the  numbei  <>t  churches  dues  not  exceed 
fifteen  it  is  well  to  select  one  member  of  the  Board  of  Trustees 
from  each  church.  This  may  be  accomplished  by  framing  the  by- 
laws accordingly.     In  case  the  number  of  churches  interested  i> 


38  ORGANIZATION    OF    HOSPITALS 

less  than  the  number  of  trustees  desired,  one  trustee  may  be  chosen 
from  each  one  of  the  smaller  churches,  and  two  or  more  from  eacli 
of  the  larger  ones.  In  ease  the  number  of  churches  greatly  ex- 
ceeds the  lmmlter  of  trustees  desired,  the  churches  may  be  grouped, 
and  each  group  be  represented  upon  the  Board  by  one  member. 
It  is  hest  to  have  a  definite  system  established  at  the  outset,  as 
this  will  eliminate  a  greal  amount  of  jealousy  and  trouble  later  on. 

It  is  well  in  church  hospitals  to  guard  against  too  large  rep- 
resentation of  the  clergy  upon  tiie  Board  of  Trustees,  as  experi- 
ence has  shown  that  the  qualities  which  result  in  distinction  in 
this  profession  rarely  produce  men  who  can  wisely  conduct  im- 
portant business  enterprises;  and  unless  the  majority  of  the 
trustees  of  a  hospital  are  competent  business  men  the  institution 
cannot  possibly  thrive. 

The  manner  of  selecting  the  trustees  must  be  the  same  in 
church  hospitals  as  in  hospitals  under  the  control  of  philanthropic 
societies;  tin1  same  is  also  true  regarding  their  term  of  service. 

ELECTION  ( )F  TRUSTEES. 

The  methods  in  vogue  for  the  election  of  Hospital  Trustees  at 
the  present  time  are  so  varied  that  it  is  difficult  to  select  any  one 
method  which  is  at  all   satisfactory. 

The  plan  which  has  probably  fewer  had  features  than  any 
other  is  what  is  known  as  the  self-perpetuating  method  after  the 
election  of  the  first  Board  of  Trustees.  The  Board  itself  elects 
the  successors  at  the  stated  periods  indicated  above. 

The  Board  may  he  limited  in  its  choice  to  the  members  of  the 
association  or  organization  which  supports  the  institution,  or  it 
may  be  limited  in  as  many  directions  as  the  special  conditions  un- 
der which  the  institution  has  been  created  demand.  But  the  pri- 
mary principle  involved  lies  in  the  fact  that  each  succeeding  mem- 
ber of  the  Board  of  Trustees  will  be  elected  by  those  who  have  an 
intimate  knowledge  of  the  necessities  of  the  institution  because  of 
the  experience  they  have  gained  during  their  management  thereof. 
Whatever  the  tendencies  of  any  individual  member  might  be,  the 
tendency  of  the  Board  as  a  whole,  is  sure  to  be  for  the  good  of  the 
institution. 

Where  this  method  has  been  tried  it  has  generally  been  very 
satisfactory.  The  only  serious  difficulty  lies  in  the  danger  of 
making  use  of  the  patronage  of  the  institution  for  the  purpose  of 
giving  employment  to  relatives  and  intimate  friends.  This  evil 
can  be  eliminated  more  or  less  successfully  by  passing  a  by-law 
for  the  guidance  of  the  Board  of  Trustees  which  prevents  the  em- 
ployment of  relatives  in  any  of  the  salaried  positions.     It  is  true 


ORGANIZATION    OF    HOSPITALS  39 

that  this  mighl  result  in  a  certain  amount  of  unnecessary  hardship 
to  some  worthy  persons  related  to  some  member  of  the  Board  of 
Trustees,  but  the  likelihood  of  this  is  so  slighl  that  it  need  not 
be  considered. 

The  member  of  such  a  Board  who  Tails  to  perform  his  part 
of  the  labors  involved  in  the  conduct  of  the  work  is  not  likely  to 
be  re-elected  by  his  colleagues  because  they  have  bad  an  abundant 
opportunity  to  determine  his  lack  <>f  value;  a  tact  of  which  those 
outside  of  the  Board  of  Trustees  might  he  entirely  ignorant. 

It  is  however  important  that  if  the  self -perpetuating  system 
be  adopted,  the  period  of  service  he  sufficiently  long  to  make 
the  members  of  the  Board  thoroughly  familiar  with  each  other's 
methods  during  their  term  of  service. 

Another  method  of  election  which  has  been  mure  commonly 
employed,  and  which  with  the  long  term  of  service  fias  also  been 
satisfactory,  is  by  ballot  of  the  members  of  the  central  organiza- 
tion; each  member  having  one  vote  and  the  person  receiving  a 
plurality  being  elected  for  the  period  of  service,  or  for  the  time 
for  which  the  vacancy  is  to  be  filled.  This  method  leaves  greater 
opportunity  for  political  manipulations,  or  intrigue,  but  if  the 
plan  is  so  arranged  that  not  more  than  one  member  of  th"  Board 
is  elected  each  year,  or  each  second  or  third  year,  then  the  danger 
from  this  source  is  not  great. 

A  third  method  which  seems  to  be  more  advantageous  con- 
sists in  the  election  by  ballot  by  the  members  of  the  organization, 
of  the  members  of  the  Board  of  Trustees  from  a  limited  number 
of  persons  nominated  by  the  existing  P>oard.  In  this  way  the  per- 
sons having  the  greatest  amount  of  experience  can  select  a  limited 
number  of  persons,  anyone  of  whom  possessing  the  qualities  which 
seem  desirable  to  those  having  had  the  greatest  amount  of  expe- 
rience. It  is  clear  that  in  this  way  the  members  of  the  existing 
Board  cannot  independently  lill  the  vacancy,  and  any  member  of 
the  Board  whose  term  expires  must  obtain  the  sanction  of  the 
members  of  the  organization  iii  order  to  be  re-elected  to  his  posi- 
tion. In  case,  however,  a  new  member  is  elected,  be  will  have  to 
serve  a  considerable  period  of  time  before  he  can  have  any  harm- 
ful degree  of  inlluelice. 

ELECTION   BY   NUMEROUS  ORGANIZATIONS. 

Occasionally  the  organization  supporting  a   hospital   is  com 
posed  of  a  aumber  of  sub-organizations.   In  case  the  firsl  plan  of 
election  of  Trustees  is  chosen,  it  may  be  wise  to  make  it  imperative 
to  elect  one  or  more  members  from  each  of  these  sub-organizal  ions. 

In  case  the  second  method  is  adopted  it  may  be  wise  to  have 


41 1  ORGANIZATION    OF    HOSPITALS 

successive  members  chosen  by  the  various  sub-organizations  in  a 
different  order. 

When  the  third  method  is  selected  it  may  be  well  to  have  the 
existing  Board  nominate  members  successively  from  the  various 
sub-organizations  in  order  to  secure  a  fair  distribution  among  these 
various  bodies. 

It'  the  hospital  is  supported  by  a  stock  company  the  Trustees 
must  of  course  be  elected  in  the  manner  by  which  Trustees  of 
other  stock  companies  are  elected.  Here  again,  it  is  of  importance 
thai  the  same  plan  heretofore  advised  be  adopted  to  secure  per- 
manency in  office. 

If  the  hospital  is  a  public  institution  supported  by  the  taxa- 
tion of  property  owners,  then  the  members  of  the  Board  of  Trus- 
tees -hould  I.,,  elected  by  popular  vote,  again  for  a  long  period  of 
service,  or  they  should  be  appointed  by  one  of  the  principal  officers. 

It  really  matters  little  how  the  selection  of  the  Board  of 
Trustees  is  made,  provided  the  dangers  pointed  out  are  guarded 
against.  In  order  to  make  this  more  emphatic  it  may  be  well 
to  recapitulate: 

Secure  men  of  integrity  and  business  capacity,  who  will  be  in- 
terested in  the  institution,  who  possess  the  willingness  as  well  as 
ability  to  give  time. 

The  term  of  office  must  be  a  long  one  in  order  to  secure  expe- 
rience. The  plan  must  provide  for  conditions  which  will  make  the 
Board  as  nearly  as  possible  non-personal. 

What  has  been  said  regarding  the  selection  of  the  Trustees 
<>!'  hospitals  conducted  by  philanthropic  societies  is  equally  true 
in  case  the  institution  is  conducted  by  any  church  or  medical  school, 
corporation  of  physicians,  or  by  wage-earners'  societies,  or  by 
private  corporations. 

When  a  Board  has  been  established  it  is  important  that  the 
entire  business  be  placed  and  left  in  the  hands  of  such  Board,  pre- 
cisely as  in  commercial  affairs.  The  stockholders  of  a  corporation 
place  their  property  completely  in  the  hands  of  a  Board  of 
Directors,  and  interfere  with  their  action  only  in  case  of  dishonesty 
or  gross  mismanagement. 

From  the  fact  that  hospitals  are  philanthropic  institutions  it 
frequently  happens  that  this  very  principle,  which  is  absolutely 
necessary  to  secure  success  in  any  direction,  is  overlooked  and 
that  every  one  having  the  slightest  interesl  in  the  institution  feels 
called  upon  to  participate  in  its  management.  This  might  seem 
impertinent  if  a  study  of  existing  conditions  did  not  show  this 
tendency  to  be  entirely  reasonable.  It  is  as  natural  for  the  in- 
terested   person    who   has   no  official    right   to   interfere   with   the 


ORGANIZATION    OF   HOSPITALS  41 

management  of  a  hospital  to  feel  moved  to  take  niton  himself  the 
privilege  or  duty  of  interfering,  as  it  is  to  reach  onl  for  the  Lines 
when  ridiiii>  with  a  careless,  inattentive  or  mcompetenl  driver. 

If  in  business  corporations  the  persons  in  authority  wen-  to 
apply  themselves  to  their  <lnties  with  the  same  degree  of  atten- 
tion (or  inattention)  that  is  often  given  hy  those  who  have  the 
management  of  hospitals,  the  stockholders  would  soon  force  the 
concern  into  the  hands  of  a  receiver.  If,  however,  the  Board  of 
Trustees  is  formed  and  maintained  according  to  the  outlines  given 
above,  it  is  plain  that  those  interested  will  see  thai  the  ones  in 
charge  of  the  institution  can,  and  do,  carry  on  its  affairs  with  so 
much  ability,  capacity  and  attention,  that  they  will  he  as  ready  to 
leave  it  in  the  hands  of  these  Trustees  as  they  would  he  to  leave 
the  interests  of  their  business  enterprises  in  the  hands  of  a  compe- 
tent Board  of  Directors. 


CHAPTER  III. 

OFFICERS  AND  AUTHORITY. 

Having  secured  the  Board  of  Trustees  having  all  of  the  de- 
sirable qualities,  we  may  give  our  attention  to  the  matter  of  man- 
agement of  the  institution. 

Tt  perhaps  may  seem  needless  to  say  that  the  management  of 
hospitals  must  be  based  upon  simple  business  principles.  Yet 
these  institutions,  except  those  known  as  strictly  private  hospitals, 
always  contain  the  element  of  charity,  which  should  not  in  any  way 
interfere  with  the  fundamental  idea  of  conducting  them  strictly 
according  to  methods  known  to  be  necessary  in  every  business  en- 
terprise in  order  to  secure  permanency  and  success. 

One  of  the  difficulties  that  one  encounters  at  the  outset  lies 
in  the  fact  that  the  income  of  most  hospitals  is  relatively  small,  and 
that  for  this  reason  it  is  impossible  to  secure  employes  with  un- 
usual experience  or  business  capacity.  It  is  consequently  neces- 
sary to  use  a  system  in  all  of  the  business  affairs  of  the  institu- 
tion so  simple  that  any  intelligent  person  with  a  willingness  to 
learn  can  comprehend  and  do  his  share  in  Carrying  out  the  details 
of  such  system  without  much  risk  of  making  errors. 

As  to  the  matter  of  experience  it  can  be  affirmed  that  it  is  not 
difficult  to  obtain  capable  persons  for  performing  all  of  the  duties 
involved,  provided  the  same  methods  are  employed  in  their  selec- 
tion that  would  be  employed  in  any  other  important  work. 

If  the  best  person  that  can  be  secured  is  selected  for  every 
position  in  question,  consistenl  with  the  amount  of  money  avail- 
able, there  need  be  no  difficulty  in  obtaining  satisfactory  service. 
If,  however,  the  institution  is  made  the  dumping  ground  for  in- 
competents who  are  maintained  in  their  positions  without  regard 
to  the  quality  or  quantity  of  service  they  render,  and  because  of 
some  pressure  that  is  brought  to  bear  in  their  favor  from  without, 
then  quite  the  opposite  must  be  expected. 

Good  service  can  best  be  obtained  by  following  a  form  of  civil 
service,  which  selects  each  person  for  the  position  in  question  be- 
cause of  his  special  fitness,  and  places  each  department  under  the 
head  of  one  responsible  for  this  department,  and  makes  it  impos- 
sible for  any  one,  whatever  his  position  may  be,  to  interfere  with 


OFFICERS   AND    AUTHORITY 


4.'5 


o   <~ 

X  o 


No.    1 — Diagram,  of  Authority  for  Large  Hospital 


Secretary. 


President. 


Treasurer. 


Librarian. 

Records  of  board  meetings. 
Records  of  work  done  by  stall 


President  of    Medical   staff. 


Superintendent 
ol   N'urses 


Bead  Nurses  I  ,,     ,, 

intendent.     '    nurses 
Maids  and  ordei 


Resident  staff  including  internes  and 
externes. 


Heads    of    vari- 
ous medical 
departments. 


Auxiliary  Committees  according  to  require- 
ments.   'Ihe  fewer  the  better. 


I   Members  of  each  de- 
part inent. 
Assistants  of  each  de- 
partment . 

I   Endowment. 

D  'nations. 
I   Entertainments. 

Library. 
I  Linen. 
I   Delicacies. 
I  Flowers. 


Superin- 
tendent of 
Hospital. 


Matron. 


Engineer. 


Stenographer. 
Book-keeper. 


\  Chief  cook. 

-  Headlaun   ress. 

(  Head  waitress.     '      t0  requirements. 


<  Assistants  accordii  g 


Fireman. 
Electrician. 
Elevator  man. 
House  Carpenter. 


\  Collections. 

-    Auditing  Accounts. 

'   Disbursements. 


No.   2. — Diagram  of  Authority  for  Hospital  oj   Moderate  Size. 

I   Secretary. 


President. 


Treasurer. 


(   Records  of  board. 

-    Record  of  work  by  staff  members. 

'   Histories  of  patients. 


superintendent 
of  Nurses. 


f  Head  Nurses.  (  . 

Night  Super-   -    '  '""' 

Lntendent.     '  nurses- 
I  Maids. 


President  of  Medical  Staff. 


Resident  staff  including  internes, 

i 
\ 


Beads    of    vari 
mis  depart- 
ments. 


f  Members  of  depart- 
ments. 

!     Assistants  of  depart- 
L      ments. 


Auxiliary    Committee    according 
ments.     The  fewer  the  better. 


to   re<iuire- 


Matron. 


Engineer. 
( Ihief  eook 

Head    lanmhes 
Head  wait  ress. 


Endowment. 
Library . 
Linen. 
De  Icaoies. 
Flowers. 

1    Fireman. 
1   evator  man 
Electrician. 
Souse  Carpeni 

<■   Assistants  according  to 
1      requirements. 

j    Assist  ants  at rdinglo 

1      requirements. 

t    Assistants 

1      require nts. 


j  Collections. 

<  Book-keei 

/   Disbursements. 


44  OFFICERS   AND   AUTHORITY 

any  given  department  except  through  the  head  of  such  department. 
In  order  to  make  this  principle  clear,  the  accompanying  diagram  of 

authority  will  be  found  useful. 

For  many  years  the  Idea  seems  to  have  been  accepted  that 
philanthropic  work  can  be  done  by  any  one  without  regard  to  his 
having  been  successful  in  previous  undertakings;  although  his 
preceding  failures,  in  most  instances,  must  necessarily  have  been 
due  to  unreliability,  indolence,  indecision,  incapacity,  lack  of  judg- 
ment and  lack  of  tact ;  and  too  often  a  congenital  or  acquired  form 
of  impudence.  This  is  true  to  so  great  an  extent  that  in  many 
philanthropic  institutions  the  moment  one  enters  the  place 
and  comes  in  contact  with  the  various  employes,  one  is  impressed 
with  what  might  be  properly  called  an  unwholesome  moral  and 
intellectual  institutional  atmosphere.  Every  close  observer  who 
has  visited  a  large  number  oi'  hospitals  must  have  encountered  this 
condition  many  times. 

The  cause  of  this  lies  in  the  lack  of  selection.  Either  the 
head  of  the  institution,  or  the  heads  of  some  of  the  important  de- 
partments, lacks  the  necessary  stamina  or  judgment,  or,  they  are 
forced  to  accept  their  subordinates  not  in  accordance  with  their 
judgment,  but  because  of  outside  influences.  This  is  especially  true 
in  institutions  in  which  a  strong  pressure  is  felt  from  the  side  of 
the  clergy,  and  from  the  side  of  the  ladies'  auxiliary  boards. 

"With  the  introduction  of  active  competition  the  principle  of 
natural  selection  must  sooner  or  later  eliminate  this  drawback. 
In  order  to  exist  institutions  will  be  compelled  to  place  at  the  heads 
of  the  various  departments  persons  who  have  the  necessary  force 
of  character  and  judgment  to  appreciate  the  fact  that  success  must 
depend  upon  the  elimination  of  this  evil. 

I  [aving  secured  properly  qualified  heads  for  the  various  depart- 
ments, it  is  important  to  have  the  organization  so  complete  that 
there  can  be  no  doubt  concerning  the  lines  of  authority.  The  ac- 
companying diagrams,  which  must  of  course  be  elaborated  to 
suit  the  conditions  of  any  given  case,  plainly  show  the  various 
lines  of  authority. 

Each  person  in  this  arrangement  is  responsible  to  but  one. 
He  goes  to  but  one  for  bis  orders  and  for  his  advice.  In  case  his 
superior  is  incompetent  from  some  cause,  any  dispute  can  he  car- 
ried to  the  person  above,  and  so  on  to  the  President  of  the  Board 
of  Trustee-,  and  by  him  to  the  Board  of  Trustees. 

This  system  also  outlines  a  definite  channel  through  which  the 
various  heads  of  departments  come  in  contact. 

In  preparing  a  diagram  of  authority  the  name  of  each  official 
and  employe  should  be  placed  underneath  the  office  occupied  by 


OFFICERS   AXH    AUTI-Ioi;i TV 


45 


this  position,  so  that  the  employe  himself  will  know,  by  referring 
to  the  diagram,  the  direction  of  the  lines  of  authority. 

In  table  Number  3  is  an  illustration  of  the  result  in  case  the 
lines  of  authority  are  not   adhered  to.     This  table  would  fairly 


Secretary. 


Records  of  board. 

Record  of  work  by  staff  members. 

Histories  of  patients. 


President. 


Head  Nurses. 

NiKht  Super 

intendent, 

Maids. 


's; 


Pupil 
nurses. 


Resident/staff  including  internes. 


,  Members  of  depart- 
eads    of    vari-     J      ments. 

us  depart-^_~^   Assistants  of  depart- 
ments^---^^   /r   \      ments. 


Endowment. 

Library. 

Linen. 

Delicacies. 

Flowers. 


FiremaD. 
Elevator  man. 
Electrician. 
I  House  Carpenter. 


Assistants  according  to 
">      requirements. 


Assistants  accotfdint:  to 
requirements. 


Head  waitress     \  Assistants  according  to 

nertu  waitress      -j      requirements. 


Collections 

Book-Keeping. 

Disbursemenis 


represent  the  result  in  some  of  the  worst  managed  institutions  of 
this  kind. 

Of  course,  it  is  impossible  in  an  illustration  of  this  kind  to 

place  a  suflieient  number  of  lines  to  indicate  all  oJ   the  possible  Con- 
ditions of  confusion  which  are  likely  to  occur.    All  of  this  confusion 


4(5  OFFICERS    A  XL)   AUTHORITY 

can.  however,  be  easily  avoided  if  each  person  in  authority  closely 
adheres  to  the  lines.  Supposing  a  member  of  one  of  the  auxiliary 
committees  finds  some  part  relating  to  the  diet  of  the  patients  un- 
satisfactory. Instead  of  upsetting  the  mechanism  of  the  institu- 
tion by  interfering  with  the  kitchen  department,  he  should  make 
a  note  of  the  condition  referred  to,  should  consider  it  carefully, 
and  should  place  his  ideas  before  the  President  of  the  Board  of 
Trustees.  That  official,  in  case  the  difficulty  lies  with  the  prepara- 
tion of  the  food,  will  refer  the  matter  to  the  superintendent  of  the 
hospital,  who  in  turn  will  discuss  it  with  the  matron,  who  in  turn 
will  interview  the  chief  cook,  and  he  will'  either  explain  the  pres- 
ent difficulty  satisfactorily,  or  refer  it. 

Should  the  complaint  lie  in  the  serving  of  the  meals,  which  is 
directly  under  the  superintendent  of  nurses,  then  the  inquiry 
would  pass  from  the  President  of  the  Board  to  the  president  of 
the  medical  staff,  and  through  him  to  the  superintendent  of  nurses, 
and  through  her  to  the  head  nurse  of  the  department  in  which  the 
difficulty  occurred. 

Should  the  difficulty  imply  a  faulty  system  in  both  of  these 
departments,  then  a  conference  may  be  held  between  the  matron 
and  the  superintendent  of  nurses.  The  initiative  coming  from 
the  President  of  the  Board,  through  the  president  of  the  medical 
department  to  the  superintendent  of  nurses,  and  if  the  matter  is 
of  great  importance,  then  it  should  be  referred  by  the  President  of 
the  Board  to  the  committee  on  housekeeping,  and  this  committee 
should  discuss  it  with  the  various  heads  of  the  departments  in- 
volved. 

It  might  seem  as  though  this  plan  would  involve  an  endless 
amount  of  red  tape,  but  as  a  matter  of  fact  it  is  the  most  direct 
way  of  collecting  faulty  methods. 

In  case  the  matter  is  of  only  slight  importance,  then  another 
plan  should  be  followed,  which,  if  invariably  employed  by  each 
one  of  the  various  heads  and  sub-heads,  must  ultimately  result  in 
a  very  perfect  system. 

If  any  person  of  authority  in  any  department  encounters  some 
feature  which  appears  to  be  harmful  to  the  institution,  but  which 
is  not  of  sufficient  importance  to  be  referred  to  the  head  of  the 
department,  the  proper  manner  in  which  to  secure  the  correction 
i>  by  asking  for  Information;  if  the  subordinate  whose  act  is  in 
question  has  a  valid  reason  for  this  act,  then  the  person  who  has 
made  the  observation  will  appreciate  such  point  and  will  be  satis- 
fied with  the  method  employed.  If  there  is  no  reason  for  doing 
the  particular  thing  in  a  faulty  way,  then  further  questioning  may 
bring  out  a  better  method. 


OFFICERS   AND   AUTHORITY  11 

The  danger  to  the  discipline  of  the  institution  from  the  use 
of  this  method  would  appear  to  lie  in  the  fact  that  a  sensitive  em- 
ploye might  look  upon  the  inquiry  as  a  criticism  or  an  interference 
outside  of  the  province  of  the  person  making  the  inquiry ;  but  with 
the  acquisition  of  competent  employes  this  system  works  admix* 
ably. 

ADHERENCE  TO  DEFINITE  SYSTEM. 

Few  heads  of  departments  appreciate  the  gresft  value  in  devel- 
oping a  plan  according  to  which  certain  things  can  always  be  done 
in  the  same  manner.  There  is,  of  course,  danger  of  establishing 
a  form  of  routine  which  Lacks  energy  and  individuality,  and  which 
in  time  must  fall  behind  in  active  competition.  This  error  must, 
of  course,  be  guarded  against  if  one  hopes  to  accomplisn  the  high- 
est character  of  development  of  an  institution. 

On  the  other  hand,  no  one  ever  does  any  one  thing  well  unless 
he  has  had  an  opportunity  to  do  it  many  times,  and  if  the  system 
is  changed  constantly,  everything  must  of  necessity  always  be  done 
poorly. 

Fortunately  there  is  a  tendency  towards  rapid  elimination 
from  the  position  of  head  of  departments  of  persons  whose  mental 
attitude  is  unstable,  so  that  ordinarily  only  the  best  fitted  person 
is  chosen  and  retained  for  each  position.  Only  those  who  have 
the  ability  to  formulate  definite  practical  plans,  and  to  adhere  to 
them,  are  likely  to  attain  and  keep  the  positions  of  heads  of  de- 
partments. A  person  in  this  position  must  possess  capacity  of 
original  thoughl  applied  to  his  particular  sphere  o\  usefulni  ss,  bill 
should  not  be  burdened  with  personal  conceit,  because  such  a 
combination  is  practically  always  lacking  in  judgment,  and  the 
incumbent  of  a  position  who  possesses  a  combination  of  these 
qualities  is  quite  certain  to  permit  a  desire  to  gratify  his  personal 
conceit  to  overshadow  his  tendency  to  do  that  which  will  resull  tn 
the  most  good  to  the  institution. 

Any  change  in  the  method  of  performing  any  given  dutj 
should  not  be  made  until  the  head  of  the  department  has  carefully 
studied  the  effects  thai  such  a  change  will  have,  not  onVj  for  the 
moment,  bul  during  the  fixed  use  of  the  changed  method  for  a 
definite  period  of  time. 

One  should  hear  in  mind  that  an  accustomed  method  which 
has  been  in  use  for  a  sufficient  period  of  time  to  become  thorough  I) 
established,  so  that  every  one  connected  with  the  department 
know-  precisely  what  every  other  one  in  this  department  would  do 
under  given  conditions,  must  produce  vastly  better  results,  both 
as  regards  quality  and  quantity  of  service,  than  a  new  procedure, 


48  OFFICERS   AND   AUTHORITY 

which  must  be  acquired  by  ever}  one  in  the  department;  although, 
thf  Latter  may  seem  to  possess  advantages  from  the  theoretical  or 
even  from  the  practical  standpoint. 

One  of  the  great  advantages  in  adhering  to  an  old  and  thor- 
oughly tried  system  lies  in  the  fact  that  experience  lias  demon- 
strated aol  only  its  strong  but  also  its  weak  points,  and  the  person 
accustomed  to  it  is  prepared  to  cope  with  all  probable  emergencies. 
The  experiences  in  this  direction  are  especially  expensive  if  meth- 
ods  are  constantly  changed;  the  service  being  found  to  suffer  both 
in  quality  and  quantity. 

In  reviewing  personal  experiences  in  hospital  management  it 
eems  that  more  harm  has  come  to  the  upbuilding  of  institutions 
from  time  to  time  by  failing  to  adhere  to  this  principle  than  from 
almost  any  other  cause. 

This  principle  applies  to  every  department  of  the  institution, 
but  more  especially  to  the  service  of  the  medical  staff,  and  the 
nursing  staff,  than  to  any  other. 

Xn  one  denies  that  if  a  manufacturing  enterprise  changed  its 
employes  from  one  machine  to  another  every  few  days,  or  weeks, 
or  months,  a  failure  in  utility  would  result.  If  a  mercantile  or 
banking  institution,  or  a  railroad,  were  to  do  the  same,  it  would 
mean  bankruptcy  within  a  relatively  short  time.  If  changes  of 
the  kind  were  made  in  the  conduct  of  a  hotel,  or  in  the  conduct  of 
any  one  of  many  human  enterprises,  experience  has  shown  that 
failure  would  be  inevitable,  and  still  in  the  management  of  a  vast 
majority  of  our  hospitals,  in  the  manner  in  which  they  are  con- 
ducted at  the  present  time — so  far  as  the  resident  medical  staff  is 
concerned — the  changes  are  so  frequent  that  nothing  but  confusion 
can  possibly  result.  This  is  not  true  to  quite  so  considerable  an 
extent  in  the  department  of  nurses  at  the  present  time  as  it  was 
formerly.  But  in  these  two  departments  there  is  still  much  im- 
provement to  be  obtained  in  this  special  direction. 

The  argument  is  constantly  made  that  it  is  a  part  of  the  busi- 
ness of  the  hospitals  to  train  the  members  of  the  medical  staff, 
and  to  train  tin  pupils  of  the  nurses  training  school.  In  order 
to  make  the  training  comprehensive  it  is  necessary  to  permit  these 
pupils  to  serve  in  every  possible  capacity.  In  this  way,  however, 
the  wide  range  of  training  is  secured  at  the  expense  of  thorough- 
ness, and  the  pupil  not  having  had  an  opportunity  to  become 
thorough  in  any  one  tiling  is  most  likely  to  be  shiftless  in  every- 
thing. Personal  tests  of  this  fad  made  experimentally  have 
demonstrated  that  some  assistants,  if  changed  from  one  service 
to  another  every  few  weeks  or  months,  will  be  almost  worthless, 
while   if  kept   on   the  same  service  for  at  least  six  months  they 


OFFICERS   AND   AUTHORITY'  4!) 

become  exceedingly  valuable,  not  only  to  the  service  itself,  but 
to  themselves,  because  they  have  developed  character  and  thor- 
oughness throughout  their  work. 

The  same  plan  has  been  tried  in  connection  with  the  training 
school  for  nurses.  Instead  of  causing  confusion  in  the  institu- 
tion by  constantly  changing  a  nurse  from  one  department  1"  an- 
other, the  younger  pupil  is  kept  upon  the  same  service  for  a  period 
of  three  months,  and  the  older  nurse  for  a  period  of  six  months; 
the  pupils  thus  learning  the  work  in  question,  and  al  the  same  time 
furnishing  to  the  institution  valuable  service. 

In  hospitals  with  various  departments  it  might  seem  unfair  to 
the  pupil  nurses  should  they  fail  to  obtain  equal  services,  for 
instance,  in  the- male  and  female  wards,  in  the  children's  and  ob- 
stetrical wards,  etc.  Schedules  have  been  arranged  for  nurses  in 
which  many  of  them  were  changed  every  week  or  fortnight,  or  at 
the  longest  every  month.  But  it  is  not  difficult  to  see  the  result 
of  such  a  foolish  plan  upon  the  development  of  the  institution. 
In  the  section  upon  the  management  of  the  various  departments 
this  will  be  further  discussed. 

APPOINTMENT  OF  OFFICERS. 

In  the  appointment  of  officers  for  hospitals  the  Trustees  must 
necessarily  be  limited  by  their  financial  resources,  both  as  regards 
the  number  and  quality  of  officers.  As  a  general  rule  it  is  better 
to  have  a  very  small  number  of  officers  with  excellent  qualifica- 
tions than  a  larger  number  without  these  elements,  because  the 
housing  and  feeding  of  incompetents  is  no  small  item,  although 
the  salaries  may  be  insignificant.  Aside  from  this  there  is  always 
the  expense  occurring  through  a  faulty  economy  of  persons  with 
poor  judgment  and  who  are  unqualified  to  perform  their  work, 
and  this  results  in  a  large  item. 

In  order  to  make  this  point  especially  clear,  two  parallel 
cases  are  given  of  hospitals  of  about  equal  size,  with  the  corre- 
sponding salaries  paid. 

No.  1. 

Superintendent  of  Hospital   $  4,000 

Superintendent  of  Nurses   1,200 

Assistant  Superintendent  of  Nurses 900 

Bookkeeper L,200 

Assistant  Bookkeeper   600 

Druggist   600 


50  OFFICERS    A.XD   AUTHORITY 

Stenographer •.        600 

Office  Clerk 240 

Nine  additional   persons,   including    office  hoys,    orderlies, 
etc.,  with  an  average  salary  of  $200  a  year. 

Total $11,140 

No.  2. 

Superintendent  of  Hospital  $  1,800 

Superintendent  of  Nurses   1,200 

A.ssistan1  Superintendent  of  Nurses  900 

Bookkeeper 400 

Office  attendant  .- : 300 

Stenographer   360 

Total $  4,960 

The  difference  of  maintaining  the  officials  of  these  two  insti- 
tutions is  not  alone  in  the  salaries,  but  in  the  housing  and  feeding. 
The  cloven  additional  employes  cost  the  institution  at  least  $3,000 
a  year  for  their  maintenance.  Their  necessary  incompetence 
makes  them,  moreover,  exceedingly  wasteful,  so  that,  all  in  all, 
the  expense  of  the  one  institution  is  more  than  three  times  as  great 
as  that  of  the  other. 

It  might  be  suggested  that  the  services  of  a  superintendent 
drawing  a  salary  of  $4,000  must  necessarily  be  more  valuable  than 
the  services  of  one  drawing  $1,800  a  year.  As  a  matter  of  fact, 
in  this  particular  instance  the  one  drawing  a  salary  of  $4,000  was 
selected  because  he  had  made  a  failure  in  life,  and  was  unable  to 
earn  the  amount  necessary  to  supply  his  own  wants  and  those  of 
his  family,  and  he  had  the  good  fortune  to  possess  friends  upon 
the  Board  of  Trustees  who  could  supply  suitable  means  for  his 
existence. 

On  the  other  hand,  the  gentleman  receiving  $1,800  a  year  had 
been  successfully  employed  in  institutional  work,  in  which  he  had 
received  only  a  small  salary,  so  that  he  could  afford  to  accept  this 
honorable  position  in  a  philanthropic  institution  for  the  sum  of 
$1,800.  Bis  former  experience  fitted  him  to  manage  the  institu- 
tion in  an  economical  way,  making  the  most  of  the  amount  of 
money  at  his  disposal,  lie  had  previously  built  up  an  institution 
from  almost  nothing  to  a  respectable  proportion,  and  was  conse- 
quently chosen,  not  because  he  needed  the  position,  hut  because 
the  institution  needed  a  man  who  had  shown  by  his  pasl  work  that 
he  had  powers  of  organization,  and  the  enthusiasm  necessary  to 
assisl  the  institution  in  its  progress. 


OFFICERS   A.ND  AUTHOBIT5  5  I 

It  will  be  seen  thai  the  salaries  of  the  two  mosl  Lmportanl  offi- 
cials in  a  hospital,  the  superintendent  and  assistant  superintendent 
of  nurses,  are  the  same  in  the  two  examples  given.  The  salary  of 
superintendent  of  nurses  has  become  relatively  fixed  and  few  capa- 
ble nurses  receive  less  than  $75  or  more  than  $150  per  month;  30 
that  the  element  of  graft  is  Less  likely  to  be  introduced  into  the 
employment  of  the  superintendent  of  nurses,  than  into  the  em 
ploymenl  of  other  officers  of  hospitals. 

From  this  point  on  there  is  again  a  marked  difference  in  the 
stipends.  The  bookkeeper  in  one  institution  receives  more  than 
twice  the  amount  of  the  one  in  the  other.  An  examination  of  the 
books,  however,  shows  those  in  the  Latter  institution  to  be  simpler, 
more  easily  comprehended,  and  equally  as  efficient  a^  those  in  the 
former.  This,  however,  was  due  to  the  fact  that  the  hooks  in 
the  latter  case  were  arranged  by  an  expert  of  great  ability,  whose 
office  it  is  to  audit  the  accounts,  in  connection  with  two  other 
gentlemen  of  the  auditing  committee,  every  month.  (Such  1  sys- 
tem of  bookkeeping  will  be  found  given  in  detail  under  a  sep- 
arate heading.)  It  should  be  stated  that  in  the  first  instance  the 
bookkeeper  is  a  man,  in  the  second  instance  a  young  lady  who 
chooses  to  occupy  this  honorable  position  in  preference  to  earn- 
ing a  Larger  salary  in  the  employment  of  some  business  house. 
Factors  of  this  kind  come  into  play  in  the  employment  of  most  of 
the  officers  of  a  hospital.  Of  course,  if  the  institution  is  finan- 
cially able  to  pay  good  salaries,  it  is  scarcely  fail  to  take  advan- 
tage of  the  willingness  of  employes  to  work  for  smaller  pay  than 
they  would  be  willing  to  accept  for  a  similar  amount  of  work  else- 
where. 

Auain,  in  the  one  instance  a  druggist  is  employed,  in  the 
other,  the  preparation  of  drugs  is  a  part  of  the  duty  of  one  of 
the  members  of  the  resident  staff,  who  receives  QO  salary. 

In  the  first  example  all  of  the  other  employes  not  correspond 
ing  to  those  in  the  second  occupy  their  various  positions  through 
some  outside  influence,  not  because  the  hospital  stands  in  need 
of  their  services,  but  because  some  one  wishes  them  to  have  this 
kind  of  employment.  The  cause  of  all  of  this  Lies  In  the  fact  that 
some  one  secures  positions  for  his  friends  a--  a  favor  to  them 
without  regard  to  the  interests  of  the  institution.  This  illustra 
tion  has  been  used  so  that  any  one  interested  in  hospital  manage 

meiit  can   reason   from  the  conditions  outlined  to  those  in   hi^  own. 
There  is  always  a  great  temptation  to  those  in  authority    to 
u>(.  their  influence  to   have   persons  appointed   to  various   posi 
lions  outside  of  their  own  department,  because  the  friends  of  such 


52  OFFICERS  AND   AUTHORITY 

persons  constantly  appeal  to  every  one  connected  with  the  insti- 
tution. 

The  physicians,  for  instance,  arc  asked  to  use  their  influence 
to  secure  the  appointment  of  nurses  in  the  training  school;  the 
superintendent  of  nurse.-  is  appealed  to,  to  secure  employment  for 
persons  in  the  matron's  department,  and  so  on. 

It  is  hetter  for  the  various  heads  of  departments  to  have  a 
definite  understanding  in  accordance  with  which  each  person  is 
to  be  the  absolute  judge  of  those  under  him,  no  matter  what  any 
other  official  has  recommended  in  the  case  of  any  given  employe. 
Moreover,  in  recommending  an  employe  to  any  one  of  the  depart- 
ments, the  employe  should  he  told  that  his  position  in  that  de- 
partment depends  entirely  upon  his  ability  to  satisfy  the  require- 
ments of  the  officer  at  the  head  of  the  department  in  question.  An 
endless  amount  of  annoyance  can  be  avoided  in  this  manner,  and 
the  institution  can  be  vastly  benefited. 

The  ultimate  control  should,  of  course,  always  rest  with  the 
Board  of  Trustees,  and  should  extend  to  every  individual  employe 
through  the  channels  indicated  in  the  diagram  of  authority:  but 
it  is  a  mistake  for  any  member  of  the  Board  of  Trustees  to  under- 
take the  employment  of  any  one  under  the  heads  of  departments. 
For  instance,  the  matron  must  select  the  cook;  the  superintendent 
of  nurses,  the  orderlies  and  chambermaids;  the  superintendent  of 
the  hospital  must  select  the  engineer,  the  elevator  man,  and  so  on. 

[f  these  various  persons  do  not  possess  the  judgment  neces- 
sary to  select  their  assistants  properly,  then  they  should  be  re- 
moved and  others  selected  in  their  place-. 

The  term  of  office  in  this  instance  should  be  during  the  good 
behavior  and  competence  of  the  person  employed,  except  in  State, 
County,  or  City  institutions,  in  which  it  may  seem  best  to  have 
the  term  for  a  definite  period  according  to  the  rules  of  civil  service. 
This  period  should  not  be  less  than  four,  nor  more  than  ten  years. 
There  should,  however,  be  a  definite  understanding  according  to 
which  the  old  employe  should  always  have  the  preference,  other 
things  being  equal.  In  other  words,  his  reappointment  should  be 
a  certainty  if  be  possesses  qualities  equal  to  those  of  his  com- 
petitor on  the  eligible  list.  This  gives  the  institution  an  oppor- 
tunity to  improve  the  service  without  dismissing  an  employe 
whose  only  failing  may  consist  in  the  fact  that  he  has  not  made  a 
reasonable  amount  of  progress  during  his  term  of  service.  It 
mighl  not  be  Fair  to  place  the  stigma  of  dismissal  upon  this  em- 
ploye, and  still  it  mighl  no1  be  fair  to  the  institution  to  suffer 
indefinitely  because  of  the  lack  of  energy  and  enthusiasm  which. 
might  be  reasonably  expected  of  any  given  employe. 


OFFICEBS   AND   A.U  I  EOR1  I  Y  Do 

THE  SUPERINTENDENT. 

The  duties  of  the  Superintendent  of  the  hospital  arc  so  cl  sarly 
defined  in  the  diagram  of  authority  that  ii  is  not  necessary  to  men- 
tion them  further  in  this  discussion. 

DUTIES  OF  THE  MATRON. 

As  shown  in  the  diagram  of  authority,  the  matron's  duty 
should  compass  the  entire  care  of  the  hospital.  In  institutions 
having  a  general  superintendent,  or  a  medical  superintendent  of 
the  hospital,  the  matron  will  perform  her  duties  under  bis  direc- 
tion. She  will  have  under  her  care  the  kitchen  department,  the 
laundry  department,  and  the  genera]  cleaning  of  the  liospital.  In 
case  there  is  no  general  superintendent,  she  also  has  under  tier 
care  the  heating,  lighting,  the  elevator  service,  and  the  general 
supervision  of  the  various  departments  in  the  liospital.  In  this 
case  she  will  receive  her  orders  from  the  President  of  the  Board. 


CHAPTER  IV. 

THE  MEDICAL  AND  SURGICAL  STAFF. 

The  selection  of  the  medical  staff  is  one  of  the  most  im- 
portant in  the  organization  of  hospitals,  especially  because  there 
is  so  little  precedent. 

The  plans  followed  in  a  few  of  the  great  hospitals  in  the  older 
cities  of  this  country,  and  those  adopted  in  the  great  hospitals  in 
Paris,  in  the  hospitals  connected  with  the  medical  department  of 
German  universities,  the  great  hospitals  in  England,  ami  those 
connected  with  medical  schools  in  other  European  countries,  were 
all  carefully  considered  at  the  time  they  were  established.  But 
they  all  date  back  to  a  time  when  medicine  and  surgery  in  these 
hospitals  were  on  an  entirely  different  basis  from  that  which  they 
occupy  at  present. 

With  the  introduction  of  these  new  conditions  new  features 
have  constantly  been  added,  but  these  have  not  always  or  entirely 
eliminated  the  features  of  the  old  system,  which  can  no  longer 
be  employed  with  advantage;  and  it  seems  as  though  much  more 
satisfactory  results  could  be  obtained  if  the  good  points  were 
selected  from  the  various  systems  and  were  applied  to  the  differ- 
ent conditions  as  they  exist  at  the  present  time.  This  has  been 
done  in  a  few  institutions  during  the  past  twenty  years,  and  as  a 
consequence  they  have  made  phenomenal  progress  as  compared 
with  other  institutions  which  have  been  developed  side  by  side 
with  them. 

The  selection  of  the  medical  staff  for  a  hospital  is  one  of 
the  most  difficult  tasks  possible,  because  the  practice  of  medicine 
and  surgery  is  to  so  great  an  extent  a  personal  matter.  A  most 
excellent  physician  in  private  practice  may  not  be  capable  of  do- 
ing the  besl  hospital  work,  because  he  lacks  system:  lie  may 
not  be  able  to  organize  his  assistants,  or  he  may  not  possess  the 
qualities  necessary  for  working  harmoniously  with  colleagues. 

Outside  of  a  few  of  the  great  cities  in  this  country  the  num- 
ber of  physicians  and  surgeons  who  have  done  active  work  in 
hospitals  is  so  small  that  no  definite  system  of  selection  can  be 
developed  as  yet. 


THE   MEDICAL   AND   SURGII  A.L  STAFF  .">•> 

For  the  present,  therefore,  the  selection  of  members  of  hos- 
pital staffs  must  depend  upon  the  following  principles: 

The  men  chosen  must  have  such  qualifications  as  will  make 
their  services  more  useful  to  the  institution  than  would  be  the 
services  of  any  other  available  persons. 

New  members  of  the  staff  should  always  be  selected  from  trie 
men  who  have  been  recommended  for  the  vacancy  by  the  existing 
staff.  This  will  insure  harmony,  which  is  absolutely  essential  to 
success. 

In  foreign  countries  the  staffs  of  hospitals  are  divided  into 
departments  and  each  department  has  virtually  a  staff  separated 
from  the  other  departments.  On  the  continent  of  Europe  there  is 
chosen  by  the  authorities  a  head  of  each  department,  and  he  in 
turn  organizes  his  department  as  an  independent  unit  by  select- 
ing his  own  assistants. 

Whenever  a  vacancy  occurs  in  the  head  of  a  department  in 
one  of  the  important  hospitals  many  men  who  have  served  for 
years  as  assistants  in  similar  departments  in  other  great  hospitals 
apply  for  the  position,  and  so  it  is  a  relatively  easy  matter  to  till 
such  vacancies  with  thoroughly  trained  physicians  and  surgeons. 
There  are  many  men  who  serve  for  years  in  the  great  university 
clinics  as  first  assistants;  after  slowly  attaining  this  position  by 
doing  conscientious  work  from  the  time  they  were  appointed  to 
the  position  of  fourth  or  fifth  assistant,  in  order  to  be  prepaid  1 
to  occupy  the  position  of  chief  of  a  department  when  some 
vacancy  occurs.  So  far  this  plan  has  not  been  followed,  as  a  rule, 
in  this  country. 

In  most  institutions,  a  physician  or  surgeon  is  usually  ap- 
pointed to  a  position  upon  a  hospital  staff  been  use  he  has  beeu 
the  family  doctor  of  some  member  of  the  hospital  board;  because 
he  has  political  influence  with  some  public  officials  in  city  or  county 
hospitals;  and  too  often  because  he  is  an  influential  member  of 
the  church  supporting  the  institution  in  question;  or  because  he 
is  a  prominent  member  of  the  staff  of  another  hospital  in  the 
same  city.  The  effect  of  such  a  method  of  selection  must  ;it  once 
be  apparent.  The  first  three  reasons  musl  result  in  dangerous 
selections,  the  last  reason  eventuates  in  the  selection  of  men 
whose  interests  must  naturally  be  with  their  old  institution,  and 
they  consequently  accept  the  second  appointmenl  for  one  of  two 
reasons:  viz.,  (1)  it  will  keep  a  competitor  from  obtaining  the 
position;  or  (2)  the  appointmenl  may  have  some  value  from  the 
standpoint  of  legitimate  advertising. 

It  is  strange  but  true  thai  hospital  Boards  will  appoinl  in- 
capable persons  to  these  important  positions  for  personal  reasons, 


56  THE    MEDICAL   AND   SURGICAL  STAFF 

while  in  their  business  they  would  not  tolerate  any  one  who  did 
not  have  the  proper  qualifications  for  performing  the  work  re- 
quired of  him. 

At  the  presenl  time  it  would  be  wise  to  demand  of  any  member 
of  ;i  staff,  a-  a  condition  of  his  selection,  that  lie  must  confine  his 
hospital  work  to  the  institution  in  question.  In  this  manner  the 
institution  can  obtain  the  entire  energy  ami  influence  of  the  man, 
hut  must  in  turn  furnish  him  honestly  with  the  best  local  facilities 
for  fear  of  Losing  him  to  a  competing  institution. 

No  hospital  can  obtain  great  distinction  for  its  work  unless 
it  follows  the  continental  plan  of  having  one  head  of.  each  depart- 
ment, together  with  the  other  members,  arranged  after  a  definite 
system  of  authority.  The  number  of  heads  in  each  instance  would 
naturally  be  the  same,  but  in  the  smaller  institutions  one  man 
mighl  serve  as  head  of  several  departments. 

In  large  hospitals,  in  which  the  work  of  any  one  department 
cannot  he  performed  by  one  man,  it  is  best  to  have  the  depart- 
ment under  one  head,  aud  to  have  the  work  of  the  assistants  under 
this  head  so  arranged  that  there  can  be  no  confusion. 

In  most  large  American  hospitals  the  service  is  divided  among 
a  number  of  men,  so  that  each  member  serves  for  a  definite  num- 
ber of  months;  or  in  other  institutions  the  service  is  arranged  so 
that  each  one  receives  his  cases  in  rotation.  If  there  are  four  men 
on  any  given  service,  case  No.  1  goes  to  the  first  man  on  the  staff, 
case  No.  2  goes  to  the  second  man,  and  so  on.  This  leads  to  an 
endless  amount  of  trouble  because  of  the  partiality  of  those  whose 
business  it  is  to  admit  patients.  The  objection,  however,  has  been 
successfully  avoided  in  some  hospitals  l>\  a-signing  all  cases 
admitted  to  the  general  wards  to  surgeon  or  physician  No.  1 
from  the  first  to  the  eighth  of  each  month;  those  admitted  from 
the  eighth  to  the  sixteenth,  to  No.  2:  those  admitted  from  the  six- 
teenth to  the  twenty-third,  to  No.  3,  and  those  admitted  from  the 
twenty-third  to  the  thirty-first,  to  No.  4. 

In  case  the  service  is  divided  between  three  men.  those  admitted 
before  the  eleventh  are  assigned  to  No.  1  ;  those  admitted  from  the 
eleventh  to  the  twenty-first  are  assigned  to  No.  2;  those  admit- 
ted from  the  twenty-nrsi  to  the  thirty-first  are  assigned  to  No.  3. 
Each  man  continues  to  care  for  the  patients  which  were  referred 
to  him  during  the  time  he  was  on  active  duty;  he  also  cares  for 
any  cases  that  are  sent  to  the  hospital  with  a  request  for  this  par- 
ticular memher  of  the  staff,  and  also  those  which  he  may  send  to 
the  hospital  personally. 

In  this  manner  the  patients  in  the  hospital  receive  better  care 
because  the  physician  can  systemize  his  work,  so  thai  while  he  is 


THE    MEDICAL   A.3STD   SURGICAL  STAI  i  57 

on  active  duty  he  will  be  constantly  prepared  to  meel  the  emer- 
gencies which  may  occur  in  the  hospital,  while  during  the  re- 
mainder of  the  month  his  time  ;it  the  hospital  can  be  limited  to  a 
definite  and  convenient  portion  of  the  day.  The  result  is  that  the 
physician  or  surgeon  maintains' a  continuous  interest  in  the  insti- 
tution throughout  the  year,  and  he  can  consequently  develop  a 
degree  of  system  in  his  work  which  would  not  be  possible  were 
he  to  serve  for  a  few  months  at  a  time,  and  then  be  entirely  off 
duty,  according  to  the  systems  which  are  in  vogue  in  many  Amer- 
ican cities. 

The  scheme  oh  page  59  indicates  a  reasonable  plan  for  the  or- 
ganization of  a  medical  staff  with  definite  Lines  of  authority. 

DURATION  OF  SERVICE. 

In  public  institutions  it  is  probably  best  to  have  definite 
periods  of  service.  In  different  European  countries  this  varies 
greatly,  and  in  this  country  there  are  only  a  few  of  the  oldesi 
institutions  that  have  a  prescribed  tenure  of  office. 

The  plan  of  dividing  the  service  into  four  active  periods  of  six 
years  each  ami  thereafter  placing  the  physician  on  the  consulta- 
tion staff  is  probably  the  best.  This  would  include  six  years  of 
work  as  interne  and  third  assistant  in  any  given  department,  or 
two  years'  service  as  interne  and  four  years  as  third  assistant  in 
one  or  more  departments.  The  last  four  years  of  this  work  would 
be  spent  largely  in  pursuit  of  scientific  investigation  or  research 
work. 

The  next  six  years  would  be  spent  in  the  capacity  of  second 
assistant  or  junior  attending  physician  or  surgeon.  Most  men 
would  naturally  not  go  further  than  this  appointment,  because  the 
number  of  positions  would  become  fewer  as  their  importance  in- 
creased. In  each  case  the  position  in  the  higher  class  which  would 
become  vacant  by  time  limit  or  resignation,  or  other  causes,  would 
be  filled  by  the  most  suitable  nam  in  the  lower  ranks. 

The  next  six  years  would  he  spent  in  the  position  of  first 
assistant  or  attending  physician  or  surgeon:  and  the  following  si\- 
years  as  chief  of  the  department.  After  this  the  service  would 
be  in  an  advisory  capacity,  without  any  responsibility,  for  an  in- 
definite period. 

With  such  a  scheme  the  authorities  of  a  hospital  can  demand 
regular  systematic  service,  and  there  musl   necessarily  be  devel 
oped  in  this  manner  a  staff  of  unusual  ability,  learning  and  skill, 
which  is  scarcely  possible  by  any  other  course. 

In  order  to  facilitate  the  practical  application  of  the  ideas 
involved  the  following  plan   of  organization,   which  has  been   in 


58  THE   MEDICAL  AND  SURGICAL  STAFE 

force  in  one  of  our  large  hospitals  (and  which  has  proven  eminent- 
ly successful),  may  serve  as  a  practical  example. 

PLAN  FOR  ORGANIZATION  OF  HOSPITAL  STAFF. 
1.  CONSULTING  STAFF. 

The  consulting  staff  should  consist  of  men  who  are  distin- 
guished for  their  learning  and  skill  and  who  have  served  upon 
the  active  staff  for  a  number  of  years,  but  are  no  longer  able  so 
to  do  because  of  their  advanced  age,  on  account  of  some  physical 
infirmity,  or  owing  to  lack  of  time  in  view  of  other  duties. 

The  members  of  the  consulting  staff  should  be  ready  to  be 
called  in  consultation  by  the  members  of  the  active  staff  in  un- 
usual cases  in  which  their  advice  may  be  desired. 

2.     ACTIVE  STAFF. 

The  active  staff  should  consist  of: 
1. — A  chief  of  the  entire  staff. 
2. — A  chief  of  each  department. 

3. — An  attending  physician  or  surgeon  in  each  depart- 
ment. 
4. — A  junior  attending  physician  or  surgeon  in  each  de- 
partment that  is  sufficiently  large  to  demand  this  ad- 
ditional member. 
The  following  division  of  the  staff  would  result: 
1. — Chief  of  the  entire  staff.* 


*In  case  thf  occupant  is  a  surgeon  his  title  should  be  Surgeon-in-Chief ;  In  case 
he  is  a  physician,  his  title  should  be  Physician-in-Chief. 


THE    MEDICAL   AND   SURGICAL   STAFF 


59 


'/ 


o 

n     o 

o 

Q 

n 

0 

O 

O 

n 

31 

3-         3* 

3* 

cr 

3* 

a* 

3*_ 

cr 

n 

0)          rt 

a> 

rt 

n 

ft> 

S" 

rt' 

o 

O        Q 

c 

p 

o 

s. 

S. 

s, 

C 

13 

w    r 

0 

O 

O 

a 

O 

g 

X 

P 

P 

n 

Q 

•a 

fD 

3- 

rt 

3 

3* 

g 

■     ^ 

3 

3; 

-1 

n 

Si 

C5. 

olog-ical 

OE 

2.       B 
O         ?3 

arq       o 

*~      o' 

p 

=2. 

o' 

o 

c 

fD 

5 

P. 

3 

IS. 
0 
p 

O 

Q 

c5. 

0 

p^ 

a 

P 

U 

EL 

rt 
5 

5" 

p 

>       € 

0     £L 
•o      0 

p 

a 

P 

-1 

fD 

1 

3 

rt 

p 

-1 

3        3 

P       a> 

i       "3 

a 

3 
2 

a 

P 

CT 

3 

2 

i—          zr 

3"      p 

5 

fD 

2 

r+ 

e    i 

B        5 

0)          -j- 

i 

Z- 

P 

2 

>         3. 

h-3 

B         B 
f*        rt 

3 
ft> 

1 

3 

3 

r— 1             '. 

r+ 

<■+ 

a 

O        : 

3 

^_t, 

^x^- 

^A— 

^ 

- 

»    > 

> 

> 

t> 

I> 

Z> 

C    ^ 

5^ 

c 

^ 

B*       S 

5'     rt 
2-     5 

fD 

a 

rt 

fD 

3.5? 

0  3 

1  £li 

3.S 

2  s 

2      rt 

0  3 

■d 

o        — 
jq          3 

ST     « 

sq 

crq 

7q 

jq 

fD 

p  5" 
rt 

p  5' 
^crq 
rt 

> 

3  a; 

a 

rt 
-i 

3 
p 

O 

5* 

crq 

O 
3; 

2 

fD 

-I 

1? 

orq  rt 

3  ^ 

jq  2. 

0 

3  x 

3'  1 

jq  rt 
0 

0 

3_ 

cq 
o 

0* 

?q 

o 

Oq 

/■ 

3 
0 

en 

o2 

rt   3 

5  P' 

op 

-. 
?q 

rt 

a 

X 

(/. 

35. 

1   • 

0'  • 

g 

»> 

pj': 

5  : 

3  ■ 

X 
o 
■J- 

a     g 

°     2 

p 
3 
& 

0 

5 
n 

S?  § 

3.     B» 
°      ft 

PC 

rt 

?i 

—   5 

a    W 

3* 

DO 

V} 

-1 
crq 

P      3 

3    iq 

&    0 

t» 

o 

5" 

fi 
C 

t-H       ""* 

B 

p 

60  THE   MEDICAL  AND  SURGICAL  STAFF 

Iii  some  hospitals  the  division  into  departments  is  somewhat 
different,  there  being  a  separate  department  for  the  eye,  and  a 
separate  department  for  the  ear;  or  the  department  for  the  eye, 
ear,  nose  and  throal  may  all  be  under  one  chief.  Such  details  can, 
of  course,  be  altered  to  suit  conditions. 

INTERNES. 

The  number  of  internes  should  depend  upon  the  number  of 
beds — one  interne  for  every  thirtj  to  forty  beds.  Their  service 
should  be  for  a  period  of  from  one  to  three  years,  according  to 
conditions. 

EXTEKNES. 

There  should  be  two  externes  for  every  interne.  Their  serv- 
ice should  he  for  a  period  of  three  to  six  months,  according  to  con- 
ditions. 

STAFF  DUTIES. 

The  duties  of  the  various  members  of  the  staff  should  be  as 
follows : 

The  members  of  the  consulting  staff  should  have  no  active 
duties. 

It  should  be  the  duty  of  the  Chief  of  the  entire  staff  to  organ- 
ize the  service  in  general.  He  should  be  responsible  to  the  Board 
of  Trustees  for  the  work  of  the  staff,  and  should  communicate  to 
the  Board  any  requests  or  suggestions  which  the  medical  staff 
may  desire  to  make,  and  should  receive  from  the  Board  any  com- 
munications their  body  may  wish  to  convey  to  the  staff  from  time 
to  time. 

He  should  have  the  duties  of  Chairman  of  the  Medical  Staff 
at  their  meetings. 

It  should  be  the  duty  of  the  chief  of  each  department  to 
organize  his  own  department,  and  to  communicate  to  the  Chief  of 
the  staff  any  requests  or  suggestions  which  the  members  of  his 
department  may  desire  to  make  from  time  to  time 

He  should  he  responsible  to  the  Chief  of  the  entire  staff  for 
the  work  of  his  department,  and  he  should  confine  his  activity  in 
the  hospital  to  his  own  branch  of  the  profession. 

He  should  have  fixed  days  and  definite  hours  of  visiting  the 
hospital,  and  should  develop  a  systematic  service.  He  should 
plan  the  work  for  the  other  members  of  his  department. 

It  should  be  the  duty  of  the  attending  physician  or  surgeon 
to  take  the  place  of  the  chief  of  his  department  in  the  latter's 
absence  from  the  city,  or  in  case  of  incapacity,  and  to  assist  the 
latter  in  carrying  out  the  regular  work  of  the  department  as  out- 


THE   MEDICAL   AND   SURGICAL  STAJ  I  61 

lined  by  the  chief.    He  should  also  have  definite  days  and  hours 
of  service.    His  activity  should  be  confined  to  his  especial  branch. 

ASSIGNMENT  OF  PATIENTS. 

Every  member  of  the  staff  should  have  the  privilege  of  send- 
ing his  patients  to  the  hospital  to  be  cared  for  in  the  private 
rooms,  in  the  private  wards,  or  in  the  general  wards  as  he  and 
they  may  desire. 

Patients  coming  to  the  hospital  should  be  assigned  by  the 
Chief  of  the  entire  staff,  or  by  some  one  whom  he  may  designate 
to  the  chief  of  the  department  to  which  they  may  belong,  accord- 
ing to  the  character  of  their  malady. 

The  chief  of  each  department  should  care  for  these  patients 
himself,  or  assign  them  to  the  attending  physician  or  surgeon  in 
his  department,  or  to  the  junior  attending  physician  or  surgeon, 
according  to  the  plan  followed  in  the  organization  of  his  depart- 
ment. 

If  the  service  is  a  large  one,  so  that  it  must  be  divided  into  a 
number  of  portions  in  order  to  secure  satisfactory  attention,  it 
is  well  at  this  point  to  make  use  of  the  plan  mentioned  above  of 
having  all  the  patients  in  a  given  department  assigned  to  one  of 
the  attending  physicians  or  surgeons  for  a  certain  number  of  days, 
and  then  for  an  equal  number  of  days  to  the  next  attending 
physician  or  surgeon,  and  so  on  throughout  the  month,  so  that 
each  man  upon  the  staff  has  certain  days  in  the  month  when  he 
has  the  entire  service  in  his  department.  The  reasons  for  this 
plan  were  given  in  our  discussion  above. 

APPOINTMENT   OF  THE   STAFF. 

The  original  staff  should  be  appointed  by  the  Board  of  Trus- 
tees in  accordance  with  the  following  plan : 

The  chief  of  the  entire  staff  should  first  be  selected  by  the 
Board  of  Trustees,  then  a  conference  between  this  chief  and  the 
Board  of  Trustees  should  be  held.  At  this  conference  the  men 
to  take  charge  as  chiefs  of  the  most  important  departments,  such 
as  medicine,  surgery  and  obstetrics,  should  be  appointed.  These 
should  then  act  as  a  nucleus  of  a  medical  staff,  and  should  locate 
men  for  the  less  important  positions,  whom  they  should  in  turn 
recommend  to  the  Board  of  Trustees.  In  case  any  member  rec- 
ommended should  fail  to  be  elected,  then  another  should  be  nomi- 
nated by  the  original  members  of  the  medical  staff  for  considera- 
tion by  the  Board  of  Trustees.  In  case  of  his  rejection,  there 
should  be  a  repetition  of  this  step  until  the  person  has  been  found 


6'2  THE    MEDICAL   AXD   SURGICAL  STAFF 

by  the  medical  staff  who  would  be  satisfactory  to  the  Board  of 
Trustees. 

For  subsequent  appointments  the  following  plan  should  pros- 
per: 

For  any  appointment  in  any  department  in  which  a  vacancy 
may  occur  the  initiative  should  always  come  from  the  chief  of 
the  department — i.  e.,  the  chief  of  the  department  should  recom- 
mend to  the  <  'liief  of  the  entire  staff  a  person  who  in  his  judgment 
is  especially  fitted  to  fill  the  vacancy  because  of  his  learning,  skill, 
honesty,  tact,  modesty,  industry,  and  especially  his  possession  of 
an  abundance  of  common  sense. 

The  Chief  of  the  staff  should  then  call  a  meeting  of  the  staff, 
and  should  ask  each  member  of  the  staff  already  appointed  for 
his  opinion  concerning  the  new  candidate.  If  the  person  in  ques- 
tion is  satisfactory  to  the  existing  staff,  then  the  Chief  of  the 
staff  should  recommend  his  appointment  to  the  Board  of  Trustees. 
After  due  deliberation  the  Board  should  appoint  the  person  rec- 
ommended, or  reject  him,  according  to  the  judgment  of  its  mem- 
bers. 

In  case  a  candidate  who  has  been  recommended  by  the  staff 
is  rejected  by  the  Board,  the  whole  process  should  be  repeated 
and  another  recommendation  made  until  a  suitable  person  is  found. 

Another  plan  which  has  also  been  employed,  and  which  has 
some  advantage  inasmuch  as  it  may  facilitate  the  election,  in  that 
it  compels  the  Board  of  Trustees  to  make  a  choice,  has  the  disad- 
vantage of  compelling  the  medical  staff  to  recommend  men  who 
may  not  be  perfectly  suited  to  the  position. 

According  to  this  system,  the  medical  staff  has  three  candi- 
dates for  every  vacancy,  signifying  its  preference  as  to  first,  sec- 
ond and  third.  The  Board  of  Trustees  is  compelled  to  choose  one 
of  these  three  candidates  without  regard  to  the  preference  signi- 
fied by  the  staff,  although  ordinarily  this  preference  would  be 
considered.  The  difficulty  in  this  plan  lies  especially  in  the  fact 
that  it  will  many  times  be  almost  impossible  to  find  three  men 
who  could  suitably  fill  a  given  position. 

In  case  any  member  of  the  >tal'i  lias  any  serious  objection  to 
the  recommendation  of  a  candidate  whom  the  chief  of  any  depart- 
ment may  suggest,  this  candidate  should  be  discarded  and  the 
chief  of  the  department  in  which  the  vacancy  may  exist  should 
select  another  candidate. 

The  appointment  should  he  for  one  year,  with  the  under- 
standing that  the  Board  will  renew  the  appointment  every  year  so 
Long  as  the  member  of  the  staff  pei  forms  his  duties  honestly,  skill- 
fully, ami  punctually. 


THE    MEDICAL   AXD   SURGICAL   STAPf  63 

In  case  two-thirds  of  the  members  of  the  active  staff  should 
deem  it  best  for  the  welfare  of  the  institution  to  secure  the  removal 
of  any  member  of  the  staff,  their  written  request  to  the  Board 
should  cause  the  latter  body  to  forego  his  reappointment  at  the 
end  of  the  year,  and  to  notify  the  staff  of  the  vacancy. 

This  feature  is  desirable  because  of  cases  in  which  members 
of  the  staff  have  become  incapable  of  performing  satisfactory 
service  for  the  institution,  either  from  physical,  mental  or  moral 
incapacity.  It  has  often  been  difficult  to  relieve  the  institution 
from  this  burden  without  causing  a  most  unfortunate  scandal. 
The  plan  mentioned  would  not,  however,  be  safe  unless  the  Board 
of  Trustees  were  permanent,  as  indicated  above  in  the  organiza- 
tion of  trustees. 

SELECTION  OP  THE  STAFF. 

In  selecting  members  of 'the  staff,  it  seems  that  the  following 
plan  would  give  the  best  results  for  the  hospital. 

All  members  of  the  staff  should  be  chosen  because  of  their 
superiority  in  honesty,  learning,  skill,  modesty,  tact,  industry,  un- 
selfishness, kindness,  sincerity  and  punctuality. 

The  chiefs  of  departments  should  be  men  of  distinction.  In 
the  great  cities  in  which  there  are  medical  schools  it  is  preferable 
that  they  be  professors  or  instructors  in  one  of  the  important 
schools.  Whenever  possible  the  junior  attending  physician  or 
surgeon  should  be  promoted  to  this  position  in  case  of  a  vacancy, 
provided  he  has  developed  the  necessary  qualities  fitting  him  for 
the  increased  responsibility. 

The  junior  attending  physicians  and  surgeons  should  be  still 
younger  men,  especially  noted  for  their  ability  as  students;  men 
who  are  willing  to  give  a  considerable  amount  of  time  to  scientific 
study  and  original  investigation  under  the  direction  and  advice  of 
the  chiefs  of  the  various  departments. 

The  resident  pathologist  should  he  a  man  who  lias  given  es- 
pecial attention  to  the  branch  of  pathology  in  one  or  more  oi  the 
great  laboratories  in  this  country  or  abroad.  Ee  should  give  his 
entire  time  to  the  hospital,  and  he  should  be  paid  a  suitable 
salary. 

SELECTION  OF  CNTEBNES. 

The  internes  should  he  selected  by  the  Chief  of  the  staff. 
with  the  advice  of  the  chiefs  «.r  the  various  departments,  Prom 
the  men  who  ha ve  served  as  externes,  the  excellence  oi'  their  serv- 
ice determining  their  selection.  All  internes  should  he  graduated 
within  one  year  previous  to  their  appointment. 


04  THE    MEDICAL  AND   SUKGICAL  STAFF 

SELECTION  OF  EXTEENES. 

These  should  be  chosen  by  the  Chief  of  the  staff  froDi  appli- 
cants from  the  various  important  medical  schools,  each  applicant 
being  required  to  bring  two  satisfactory  letters  of  recommenda- 
tion from  members  ol  the  faculty  of  his  school.  They  should 
pass  a  competitive  examination  or  should  be  required  to  have  a 
creditable  standing  in  their  classes.  They  should  have  completed 
the  sophomore,  and  probably  the  .junior,  year  in  their  course  at 
the  medical  college;  and  they  should  serve  a  period  of  from  three 
to  six  months  in  the  capacity  of  assistants  to  the  internes. 

This  plan  contains  the  following  important  features  which 
must  result  in  the  formation  of  a  staff  which  will  be  recognized 
everywhere  as  the  best  possible  under  the  conditions  existing  in 
most  hospitals : 

It  will  insure  stability  in  the  staff,  because  the  reappointment 
is  insured  for  all  time  so  long  as  the  occupant  of  a  position  is 
physically,  professionally  and  morally  competent  to  fill  this  posi- 
tion. 

It  will  enable  men  of  great  skill  and  learning  to  concentrate 
their  energies  upon  the  development  of  the  institution,  because 
they  can  feel  certain  that  they  are  building  up  a  work  of  which 
they  are  permanently  a  part.  They  can  afford  to  be  liberal  with 
the  poor  ami  those  in  moderate  circumstances,  because  they  will 
have  a  place  where  their  wealthy  patrons  will  get  the  best  possi- 
ble care;  and  the  fact  that  provision  is  made  for  the  care  of 
wealthy  people  will  ultimately  result  in  large  endowments  which 
will  support  the  institution  for  the  poor  for  all  time  to  come. 

This  feature  applies,  of  course,  only  to  the  hospitals  contain- 
ing both  private  rooms  for  the  care  of  wealthy  patients  and  wards 
for  the  care  of  the  poor. 

[n  case  of  hospitals  devoted  entirely  to  the  care  of  charity 
patients  the  benefit  to  the  members  of  the  staff  must  come  through 
the  factdhat  the  institution  enables  them  to  increase  their  learn- 
ing and  skill,  and  to  give  them  an  opportunity  of  utilizing  the 
patients  for  clinical  teaching. 

This  course  makes  a  harmonious  staff  absolutely  positive, 
because  each  new  member  will  be  selected  by  the  staff  of  the  de- 
partment in  which  he  is  to  work,  and  will  be  accepted  by  all  the 
other  members  before  he  is  appointed  by  the  Board. 

It  will  make  it  possible  for  the  chief  of  each  department  to 
develop  the  ability,  skill  and  Learning  of  the  other  members  of  his 
department,  because  being  chief,  and  having  selected  these  mem- 
bers himself,  they  will  be  men  whom  he  will  be  able  to  trust. 


THE    MEDICAL   AND   SURGICAL   STA]  I  65 

The  fact  that  they  have  been  accepted  by  the  other  members  of 
the  staff  will  make  it  certain  that  his  selection  has  been  for  the 
best  interests  of  the  institution  and  not  for  selfish  purposes. 

The  younger  members  of  such  a  staff  will  be  sure  to  obtain 
appointments  in  other  important  institutions  after  having  served 
sufficiently  long  to  have  acquired  skill  and  Learning,  consequently 
there  will  not  be  the  tendency  to  intrigue  againsi  their  chief  in 
the  institution  in  question. 

It  will  be  necessary  to  pay  a  salary  to  the  resident  pathologist, 
because  he  must  be  a  man  of  unusual  learning  and  must  give  the 
institution  his  entire  time.  During  the  three  years  of  service, 
however,  he  will  have  an  opportunity  of  creating  a  reputation 
that  will  make  it  possible  for  him  to  secure  a  position  in  some 
university  at  the  end  of  that  time,  should  he  desire  it.  The  sal- 
ary should  be  graded,  being  approximately  doubled  each  suc- 
ceeding year  for  three  j^ears,  which  will  make  the  average  sum  a 
little  greater  than  that  received  for  the  middle  year. 

As  indicated  above,  this  composes  the  organization  of  the  staff 
of  a  large  hospital  in  a  large  city  conducted  under  the  auspices  of 
a  church  organization. 

A  careful  study  of  this  plan  will  convince  one  that  it  pos- 
sesses exceedingly  strong  features,  provided  a  man  of  unusual 
ability  can  be  secured  for  the  head,  who  will  concentrate  his  ener- 
gies upon  his  particular  institution.  Were  he  to  follow  the  foolish 
plan  of  dividing  his  energies  among  a  number  of  enterprises,  it 
would  necessarily  mean  bankruptcy  for  the  institution  in  ques- 
tion, because  its  success  must  obviously  depend  upon  the  ability, 
judgment,  energy,  enthusiasm,  concentration,  punctuality,  and 
powers  of  organization  of  this  head. 

In  discussing  this  form  of  organization,  it  has  been  urged 
many  times  thai  the  loss  of  such  a  head  would  again  of  necessity 
destroy  the  prosperity  of  the  interests  under  charge;  and  that 
the  disability  of  this  head  would  mean  disaster  to  the  institution. 
This  is  an  argument  that  would  have  weight  only  in  case  such 
positions  were  not  sought  after  by  men  of  unusual  ability.  On  the 
continent  of  Europe  experience  has  shown  for  man>  years  that 
there  is  no  danger  from  this  source. 

Another  objection  lies  in  the  fact  that  this  system  places 
undue  powers  in  the  hands  of  one  individual,  which  il*  used  for 
selfish  ends,  would  again  harm  the  institution.  Such  an  event 
would,  however,  ruin  the  prospects  of  the  individual  a1  the  same 
time,  consequently  he  could  scarcely  afford  to  take  chances,  even 
though  he  might  primarily  be  moved  by  selfish  motives.  Prob- 
ably the   only  conditions   allowing  of   the   above   are   afforded    in 


66  THE    MEDICAL  -VXD   SURGICAL  STAFF 

largely  endowed  institutions,  because  here  the  bad  results  of  such 
a  selfish  practice  would  not  lead  to  bankruptcy.  In  such  institu- 
tions, however,  it  would  be  very  foolish  not  to  provide  necessary 
precautions  in  the  management  of  the  finances,  which  would  again 
make  it  almost  impossible  for  unscrupulous  men  to  get  the  posi- 
tion of  heads  of  departments. 

The  form  of  organization  provides  another  remedy  which 
could  be  applied  in  case  the  chief  of  any  department  failed  in  this 
direction.  The  Board  of  Trustees  in  the  annual  election  of  the 
medical  staff  could  leave  the  vacancy  in  this  particular  depart- 
ment, and  call  upon  the  staff  for  nomination.-  from  which  to  fill 
this  vacancy. 

Another  possible  fault  has  been  hinted  at  above.  The  possi- 
bility of  appointing  incompetents  to  the  subordinate  positions  like 
those  of  attending  physician  or  surgeon,  or  junior  attending  physi- 
cian or  surgeon,  from  selfish  motives  on  the  part  of  the  chief  of 
the  department,  or  because  of  fear  of  competition  from  an  un- 
usually capable  person  in  any  one  of  the  subordinate  positions. 
This  contingency  would  be  favored  by  the  fact  that  the  initiative 
in  all  of  these  departments  in  the  appointment  of  such  physicians 
and  surgeons  must  come  from  the  chief.  The  latter,  however, 
having  only  the  right  to  nominate,  will  naturally  not  propose  a 
person  whose  lack  of  ability  will  cause  him  to  be  undesirable  as 
a  colleague  to  the  remaining  members  of  the  staff,  any  one  of 
whom  has  a  right  to  prevent  Ins  acceptance  by  objecting  to  the 
recommendation  of  this  person  to  the  Board  of  Trustees. 

The  system  should  contain  a  reasonable  age  limit,  or  a  limit 
in  the  number  of  years  of  service.  In  the  European  centers  there 
is  an  age  limit  of  sevent}'  years,  which  for  the  conditions  in  this 
country  is  possibly  five  years  too  high. 

In  some  of  the  other  countries  the  service  is  limited  to  from 
fifteen  to  twenty-five  years  as  chief  of  a  department.  The  latter 
period  seems  to  be  the  more  desirable  for  obvious  reasons. 

This  form  of  organization  could  not  be  applied  to  smaller  hos- 
pitals, neither  could  it  be* applied  to  the  very  large  institutions 
under  the  control  of  i lie  State.  City  or  County.  For  these  we  must 
provide  other  plans. 

In  cities  of  moderate  size,  say  up  to  100,000  inhabitants,  in 
which  there  are  not  more  than  two  or  three  hospitals,  the  course 
jusl  described  is  applicable  with  the  addition  of  the  following 
features : 

In  such  cities  there  are  many  capable  practitioners  of  medi- 
cine who  are  perfectly  competent  to  serve  upon  the  staff  of  a  hos- 
pital, and  whose  service  in  such  a  capacity  would  not  only  benefit 


THE   MEDICAL  AND   SURGICAL   S1A1J  67 

the  community,  but  also  the  institution;  but  it  is  self-evident  that 
an  unlimited  staff  would  be  ruinous,  just  as  an  unlimited  number 
of  foremen  would  be  ruinous  to  the  conduct  of  a  factory. 

These  medical  men  are  often  very  nearly  equal  in  their  quali- 
fications, therefore  beyond  the  selection  of  the  .staff  as  indicated 
above  it  would  be  difficult  to  place  all  of  the  other  available  men 
so  that  they  would  be  properly  graded,  and  so  that  there  would 
be  proper  lines  of  authority.  Still,  provision  must  be  made  which 
will  render  it  possible  for  physicians  and  surgeons  in  the  city,  who 
are  willing  and  able  to  perform  such  work  as  will  he  beneficial  to 
the  community  and  the  hospital,  to  treat  their  patients  in  the 
institution,  provided  they  are  not  affiliated  with  any  other  similar 
institution  in  the  city.  This  can  be  accomplished  in  the  following 
manner:  There  can  be  the  organization  of  a  -tall  a-  indicated 
above,  which  will  be  known  as  the  executive  staff,  and  the  mem- 
bers of  this  staff  will  be  known  by  the  titles  indicated  above.  This 
staff  must  necessarily  be  limited  to  new  members,  and  can  be 
chosen  only  when  vacancies  occur. 

There  can  be  organized  a  second  staff  whose  members  are 
selected  by  the  executive  staff,  precisely  as  are  the  members  of 
the  executive  staff  itself.  They  are  then  recommended  to  the 
Board  of  Trustees  by  the  president  of  the  executive  staff,  and 
if  elected  by  the  Board  of  Trustees,  their  service  should  continue 
indefinitely;  the  Board  of  Trustees  re-electing  each  member  an- 
nually unless  there  arise  some  reason  or  reasons  which  would  make 
the  continuance  on  the  staff  undesirable,  or  unless  either  the 
executive  staff,  or  the  visiting  staff,  by  two-thirds  vote,  recom- 
mends to  the  Board  of  Trustees  that  a  certain  member  should  not 
be  re-elected,  in  which  case  the  Board  of  Trustees  should  comply 
with  their  request. 

The  members  of  the  visiting  staff  should  have  the  privilege  of 
treating  their  patients  in  the  hospital  under  the  Mime  conditions 
accorded  to  the  members  of  the  executive  stall,  but  the  rules  gov- 
erning these  conditions  should  he  made  by  the  exec  utive.  In  other 
words,  the  members  of  the  executive  staff  should  make  all  the 
rules  concerning  the  regulation  and  managemeni  of  the  medical 
and  surgical  care  of  patients  in  the  hospital ;  bul  these  rules  should 
apply  alike  to  members  of  (he  executive  staff  and  members  of 
the  visiting '  staff,  with  the  one  exception  thai  members  of  the 
visiting  staff  would  treat  only  such  patient.-  a-  are  -cut  to  the 
hospital  by  themselves.  Patients  going  directly  t<>  the  hospital 
should  be  distributed  among  the  members  of  th<  executive  staff 
according  to  the  plan  previously  described. 

In  this  manner  every    physician   and   surgeon   who   has   the 


68  THE    MEDICAL  AND   SURGICAL  STAFF 

professional,  mental  and  moral  qualifications  which  fit  him  to 
perform  hospital  work  can  be  given  the  opportunity  if  he  de- 
sires it. 

In  case  of  vacancies  occurring  in  the  executive  staff  these 
iuld  be  filled  from  the  junior  members  of  this  staff,  providing 
these  members  have  the  proper  qualifications;  and  their  places 
in  turn  should  be  filled  from  the  members  of  the  visiting  staff. 

In  the  event,  however,  of  some  member  of  the  visiting  staff 
demonstrating  to  the  Chief  of  the  attending  staff,  in  whose  de- 
partment the  vacancy  exists,  that  he  is  superior  in  his  qualifica- 
tions to  any  other  available  members  of  the  attending  staff,  then 
the  preference  should  be  given  to  such  member  who  seems  best 
qualified  to  fill  the  position. 

The  same  is  true  in  case  a  vacancy  occurs  in  the  position  of 
chief  of  any  department.  Should  a  member  of  the  visiting  staff 
be  better  qualified,  in  the  opinion  of  the  remaining  members  of 
tiio  attending  staff,  to  fill  this  vacancy,  then  the  preference  should 
again  be  given  to  the  member  of  the  visiting  staff. 

There  is  a  distinct  advantage  in  this  procedure  from  the  fact 
that  competent  men  will  be  willing  to  serve  upon  the  visiting  staff 
in  order  to  have  an  opportunity  to  show  their  qualifications  so  that 
they  may  be  available  for  appointment  upon  the  attending  staff 
when  a  vacancy  occurs.  It  will  further  tend  to  make  the  service 
harmonious,  because  every  member  of  the  visiting  staff  will  know 
that  this  is  one  of  the  conditions  necessary  to  make  an  appointment 
to  the  attending  staff  possible.  This  method  has  been  tried  and 
found  satisfactory. 

In  hospitals  with  no  large  wards,  members  of  the  visiting  staff 
can  have  their  patients  so  placed  that  they  are  together  in  as  many 
wards  as  the  number  under  the  care  of  the  visiting  physician  in 
question  demands. 

In  considering  the  subject  of  hospital  construction  later  on 
the  use  of  only  small  wards  will  be  found  advised,  four  beds  be- 
ing the  most  satisfactory  number,  but  six  or  eight  being  permissi- 
ble. The  maximum  of  comfort  and  convenience  to  the  patient,  and 
to  the  physician,  especially  in  hospitals  in  which  there  are  many 
patients,  is  greatly  increased  in  this  way. 

In  every  small  town  in  which  no  practitioner  confines  his 
activity  to  any  given  held  of  work,  because  there  is  not  sufficient 
amount  of  such  work  to  occupy  his  entire  time,  it  is  often  very 
difficult  to  arrange  the  Bervice  in  the  hospital,  perhaps  because  the 
patients  have  formed  very  strong  personal  attachments  to  the 
various  members  of  the  local  profession.    Under  these  conditions 


THE    MEDICAL   AND   SURGICAL   STAFF  69 

it  has  been  found  satisfactory  in  many  instances  to  conduct  the 
hospital  without  an  appointed  hospital  staff,  but  to  permit  every 
reputable  physician  in  the  town  to  bring  his  patients  to  the  hos- 
pital, and  to  care  for  them  as  though  they  were  in  their  private 
houses. 


CHAPTER  V. 

PLANS  FOR  THE  ASSIGNMENT  OF  PATIENTS. 

Iii  order  to  prevenl  confusion,  it  is  well  to  provide  each  prac- 
titioner with  envelopes  bearing  the  name  and  address  of  hospital, 
a  blank  space  for  the  name  of  the  patient,  a  blank  space  for  the 
name  of  the  physician.  The  physician  writes  a  letter  containing 
all  the  directions  he  may  have  to  give,  signs  and  seals  it  in  this 
envelope,  writes  the  patient's  name  upon  it,  and  his  own  under- 
neath. When  the  patient  enters  the  hospital  bringing  this  en- 
velope, it  is  clear  into  whose  service  he  has  come,  and  this  must 
necessarily  relieve  any  confusion. 

In  almost  every  hospital  which  is  organized  so  that  many 
physicians  and  surgeons  treat  patients,  the  institution  has  had  an 
endless  amount  of  disagreement  (which  is  always  bad  for  its 
prosperity),  because  patients  who  entered  the  hospital  upon  the 
recommendation  of  one  physician,  through  some  error  were  placed 
innler  the  '-are  of  some  other  physician.  This  frequently  happens, 
even  when  every  one  concerned  tries  to  be  perfectly  fair.  It  is, 
of  course,  more  likely  to  happen  when  some  member  of  the  staff 
is  especially  admired  by  a  person  employed  in  the  hospital  office, 
or  by  some  of  the  members  of  the  resident  staff,  or  by  the  nurses; 
hut  even  if  there  is  nothing-  in  the  conditions  which  would  indicate 
favoritism,  it  frequently  happens  that  these  misunderstandings 
occur. 

Where  the  system  is  employed  which  provides  against  this 
in  the  manner  just  described,  the  physician  who  loses  his  patient 
doe-  h  as  a  result  of  his  own  carelessness;  because  of  the  fact 
that  the  patient  presents  definite  written  orders  which  must,  of 
course,  he  preserved  and  which  makes  an  error  in  this  direction 
under  discussion  practically  impossible,  h  may  happen  occasion- 
ally that  the  patient  will  forget  to  bring  his  instructions,  but  in 
that  contingency  the  person  admitting  the  patient  will  take  the 
proper  means  to  determine  who  the  patient  was  intended  for, 
because  he  will  have  to  account  for  the  placing  of  every  patient, 
either  by  producing  the  written  directions,  or  by  showing  a  reason 
for  having  assigned  the  patient  without  such  directions. 

In  the  staff  which  has  .just  been  described,  composed  of  a  visit- 


I  LANS   FOB   THE    \SSIOXMKNT  OF    PATIENTS  i\ 

ing  and  attending  branch,  this  plan  is  especially  important  becanse 
all  patients  who  do  not  come  with  a  definite  written  request  for 
a  certain  member  of  the  stall,  will  be  placed,  as  hospital  patient-, 
in  the  care  of  the  various  departments  according  to  the  diagnoses. 

The  practice  of  medicine  and  surgery  is  persona]  to  so  greal 
an  extent  that  to  the  uninitiated  this  precaution  will  appeal-  as 
useless  detail;  but  experience  has  shown  that  there  are  few  con- 
trivances which  will  do  more  toward  establishing  harmony  in  the 
staff  of  a  hospital  than  this  one  factor  of  the  utmost  carefulness 
in  the  assignment  of  patients. 

Another  point  which  may  be  considered  at  present  refers  to 
the  matter  of  precedent  as  regards  the  use  of  certain  conveniences 
of  the  hospital.  If  it  were  possible  to  conduct  an  institution -in 
which  each  member  of  the  staff  had  his  own  conveniences  through- 
out, the  conditions  would,  of  course,  he  ideal;  but  this  is  possible 
only  when  the  physician  or  surgeon  upon  the  staff  has  an  un- 
usually large  practice  and  keeps  the  various  items  occupied  a 
sufficient  portion  of  the  time  to  make  the  expense  of  their  use  in 
proportion  to  the  benefits  which  the  institution  derives  therefrom. 
This  refers  especially  to  examining-rooms,  operating-rooms,  dress- 
ing-rooms and  similar  conveniences. 

In  case  no  member  upon  the  stall' occupies  these  various  apart- 
ments for  a  longer  period  than  a  few  hours  each  day  i!  is  scarcely 
reasonable  that  so  much  space  should  be  set  aside  for  his  exclu- 
sive use.  We  will  consider,  for  instance1,  the  operating-room  in 
a  hospital  having  a  surgical  staff  of  from  six  lo  ten  members; 
unless  some  system  is  arranged  there  must  necessarily  be  an  end- 
less amount  of  waiting  and  a.  corresponding  amount  of  annoyance 
and  confusion. 

With  so  large  a  staff  the  hospital  should  contain  at  least  two 
operating-rooms,  and  for  institutions  containing  more  than  one 
hundred  and  fifty  surgical  beds,  there  should  be  at  least  three 
operating-rooms,  in  order  that  there  would  always  he  one  room 
free  in  case  of  an  emergency. 

Annoyance  ami  confusion  also  comes  from  establishing  dif- 
ferent hours  ami  days  for  operation  for  the  various  members  of 
the  staff.  In  every  institution  with  a  large  stall  there  must  nec- 
essarily be  some  members  who,  either  through  lack  of  method  or 
as  a  result  of  selfishness  or  disregard  for  the  convenience  of  oth 
ers,  or  again,  as  a  result  of  persona]  eon  ieit,  cannot  he  induced  to 
adhere  to  any  definite  order.  Such  persons  are  usually  of  \<  r\ 
little  value  to  the  hospital,  and  the  sooner  their  connection  is 
severed  the  better  it  will  he  for  the  prosperity  and  development 
of  the  entire  work.     Once  in  a   very   large  number  of  cases  an 


12  PLANS  FOR  THE  ASSIGNMENT  OF  PATIENTS 

institution  may  lose  the  services  of  a  genius  by  refusing  to  main- 
tain upon  its  staff  these  erratic  individuals,  but  such  a  possibility 
occur-  so  seldom  that  in  a  general  way  it  is  probably  best  to  disre- 
gard it  entirely,  especially  because  in  the  medical  profession  it  is 
in  such  cases  very  frequently  most  difficult  to  distinguish  between 
genius  and  degeneracy. 

Some  consideration  applies  to  the  special  attentions  to  which 
various  members  of  the  staff  are  entitled  from  the  members  of  the 
bouse  staff,  the  internes,  the  externes,  the  superintendent  of 
nurses,  the  head  nurses  in  the  different  departments,  etc.  If  the 
members  of  the  medical  staff  adhere  to  a  definite  schedule  they  can 
conveniently  enjoy  much  attention  which  would  otherwise  be  im- 
possible  to  give  because  of  conflicts  in  time.  The  most  important 
part  of  this  feature  becomes  plain  when  one  considers  that  with  a 
definite  schedule  the  orders  given  by  members  of  the  staff  can  be 
carried  out  systematically,  because  they  can  be  given  to  the  proper 
person  with  the  proper  authority. 

There  is,  of  course,  the  possibility  of  carrying  this  matter  to 
the  extent  of  consuming  so  much  time  in  red  tape  that  there  will 
be  none  left  in  which  to  perform  the  necessary  work  of  the  institu- 
tion, which  would  be  quite  as  bad  as  though  there  was  a  lack  of 
system. 

It  is,  however,  possible  to  avoid  both  evils,  if  one  is  patient  in 
the  development  of  a  system  according  to  the  principles  indicated 
above. 

In  arranging  the  service  of  the  resident  staff  it  is  important 
to  bear  in  mind  that  the  work  of  the  members  of  this  staff  cannot 
be  carried  on  with  any  degree  of  satisfaction  unless  the  service 
is  relatively  permanent  and  fairly  automatic. 

If  the  attendant  serves  under  any  given  member  of.  the  attend- 
ing staff  for  only  a  few  months  it  is  impossible  for  him  to  fully 
comprehend  the  system  desired  by  his  chief.  He  then  enters  the 
service  of  a  second  member  of  the  staff  and  carries  with  him  the 
partly  learned  method  of  the  firsl  member,  and  so  on  through  the 
cut i re  course  of  his  interneship. 

It  might  he  claimed  that  in  this  way  he  acquires  many  ex- 
cellent methods  of  performing  his  work  the  better  to  prepare  him 
thoroughly  to  do  his  work  independently  after  leaving  the  hos- 
pital. A-  a  matter  of  fact,  however,  he  fails  to  leai  n  any  one  meth- 
od properly,  ami  the  result  is  as  hopeless  in  the  development  of 
the  interne  ;i-  his  service  has  been  useless  to  the  institution. 

This  difficult)'  can  be  remedied  in  hospitals  that  have  a  suffi- 
cient number  of  beds  and  employ  a  corresponding  number  of 
internes.     By  having  a  senior  interne  in  each  department  on  duty 


PLANS  FOR  THE  ASSIGNMENT  OF  PATIENTS 


73 


for  at  least  six  months,  preferably  a  year  or  Longer,  and  requir- 
ing each  interne  to  serve  as  senior  in  one  department  only,  and  to 
serve  as  junior  or  as  externe  without  direct  responsibility  to  the 
staff,  but  with  responsibility  to  the  senior  internet  in  the  other 
departments. 

In  this  way  the  care  of  the  patient  does  not  suffer  and  still 
young  men  will  have  the  opportunity  of  varied  training,  and  an 
opportunity  of  responsible  service  before  leaving  the  hospital. 
They  will  also  look  forward  to  the  time  during  their  service  when 
they  will  carry  an  important  responsibility  in  eonnection  with  the 
management  of  the  institution.  The  dignity  which  goes  with  the 
service  of  senior  interne  has  an  excellent  effect  upon  the  disci- 
pline of  all  of  the  internes. 

The  cases  requiring  especially  good  judgment  are  naturally 
first  seen  by  the  interne,  because  they  come  to  the  hospital  in  the 


Xhaqnosis 


Region 


Y]oof  HisTor 


'.1 


Yla-yvie- 


J^ 


%E 


Sertftca  afUy 


S  MW 


JkJ 


jE. 


hfetrmr  Ks 


OpK 


u 


njfi 


rme 


ArtYn'tTtrsL 


Xi^r^o.Y-^ecL 


Tje.s  \i.  It 


EXHTIilT    \. 


character  of  emergencies.  Cases  of  severe  injury,  poisoning,  de- 
lirious patients,  severe  burns,  patients  entering  the  hospital  in  a 
comatose  condition,  and  many  other  Like  instances,  are  first  ex- 
amined by  the  interne,  who  has  been  on  duty  at  least  one  year 
before  he  is  allowed  to  occupy  this  important  position. 

The  following  (able  will  represent  the  service  of  internes  in 
a  properly  conducted  hospital  of  two  hundred  beds,  of  which  one 
hundred  are  surgical,  seventy-five  medical,  and  twenty-five  be- 
longing to  the  special  departments,  such  as  eye,  car.  nose,  lineal. 
skin,  neurological  and  obstetrical.  The  patients  on  the  obstetrical 
side  being  classed  with  the  surgical  patients,  and  the  patients  on 


74 


I'LANS  FOR  THE  ASSIGNMENT   OF  PATIENTS 


the  medical  side  in  the  children's  department  being  classed  with 
the  medical  patients. 

In  order  to  avoid  confusion  it  will  he  well  for  each  department 
to  have  cards  of  a  different  color,  which  are  placed  in  small  hold- 
ers on  the  doors  of  private  rooms  and  private  wards,  the  general 
wards  belonging  to  each  of  the  various  departments,  and  in  mixed 
wards  which  contain  patients  belonging  to  a  number  of  depart- 
ments. These  cards  should  be  placed  upon  a  holder  attached  to 
the  bed,  or  they  should  be  attached  to  the  record  sheet  of  each 
patient,  so  that  each  member  of  the  attending  staff,  and  each  mem- 
ber of  the  house  staff,  can  at  a  glance  distinguish  his  own  patients 
from  the  others. 

The  use  of  a  card  similar  to  the  following  is  a  great  con- 
venience in  preventing  errors  and  confusion  regarding  the  distri- 


Xhacposis 

7^eo/o>]                                                  Ho.  of  History 

hame.             ItTl.tsi^SstS  ^y^y^/.    T^ps      3>  o  n    fJ'f-JZjS     /JA- 

Aaa    Yk> 

Scrt/ice  of  JJy 

L^lix^  a.  a.  O         ^bCtS 

tf  M.W 

v.i.                    V 

lr^erioar^s          (/ 

Opfn 

I.Yflifw« 

Hischa/qeoi 

kFiqa.1 

CDiaQxios  is 

V. 

r  j 

FA  IN  HIT 


butioil  of  patients.  When  a  patient  is  admitted  to  the  hospital  the 
clerk  in  the  office  writes  the  name  and  date  upon  the  card  as  in- 
dicated in  A.  The  card  is  then  sent  to  the  senior  interne  who  has 
charge  of  the  classification,  and  he  determines  the  department  to 
which  the  patient  belongs.  Tn  case  the  patient  brings  a  letter,  this 
fact  has  been  determined  for  him.  If  the  patient  does  not  bring 
a  letter,  the  senior  Interne  will  make  the  examination  and  diag- 
nosis, and  determine  the  classification.  He  then  selects  a  card  of 
the  color  belonging  to  the  departmenl  to  which  the  patient  is  as- 
signed, and  adds  the  name  of  the  attending  physician,  the  name  of 
the  interne,  and  the  provisional  diagnosis  'mentioned  in  a  letter 


PLANS  FOR  THE  ASSIGNMENT   or    PAT1KNTS 


75 


brought  by  the  patient,  or  determined  by  the  interne  from  the  his- 
tory and  examination). 

In  the  first  instance  this  places  the  attending  physician  who 
has  sent  the  patient  to  the  hospital,  on  record  regarding  the  diag- 
nosis. In  the  second,  it  puts  the  senior  interne  on  record  regard- 
ing the  diagnosis.  This  fact  eliminates  a  ureal  amount  of  natural 
or  habitual  carelessness  on  the  part  of  these  persons. 

The  card  then  has  the  form  shown  under  B.  The  senior  in- 
terne preserves  this  form  for  the  present  as  Ins  own  record  of 
the  case  so  far  as  it  has  advanced. 

The  interne  in  whose  care  the  patient  now  rests  adds  the  im- 
portant facts  concerning  history,  the  treatment  and  progress  of 
the  case,  and,  when  the  treatment  is  completed,  he  puts  down  the 
result,  the  final  diagnosis,  and  then  he  hands  over  the  card  to  the 
senior  interne,  leaving  the  card  in  a  form  of  which  C  may  serve 
as  a  sample. 


TJiazposis 


Lsfts^ss^z^jt^q 


lu.mc 


Ct£l<22£dtS 


0 3~y*3^i!Cs 


T^o.<,      .*/-;/)     )/lsljf^     dJ. 


Age  44 


SenJW   ofUA     )4ajJ,^-    Musfc 


ILL 


<PC^<?3 


,  £f&.  ■ 


I  M  W. 


\L 


QpTn, (  ^^cLr^/^//- 


Tveyr\ar>K<; 


Tn^rne A?^-/-    /hisCot.^. 


/Vl™>ttec{  JT- JU?        L5Jt£ 


Tl^charyeA      V/    ~Q    -/90G 


Pp.SLLl-tS  T^^^l/fA^/^ 


it 


EX  II  [BIT  C. 


The  senior  interne  copies  from  this  card  upon  his  own  (lie  por- 
tion shown  in   Ivxhihit    I ). 

The  card  of  the  senior  interne  is  then  filed  as  a  pari  of  the 
general  records  of  the  hospital;  the  card  of  the  interne  in  the 
given  department,  as  a  portion  of  the  record  of  the  given  de- 
partment. 

Of  course,  these  cards  may  he  varied  to  suit  the  conditions 
of  the  service;  it  is  important  only  to  secure  uniformity,  and  to 
insist  upon  having  all  of  these  slips  carried  out  with  regularity. 


76 


PLANS   POK    THE   ASSIGNMENT    OF    PATIENTS 


If  desired  by  the  attending  physician,  the  important  facts  con- 
cerning the  history  and  treatment  of  each  case  may  be  written  on 
the  reverse  side  of  the  card,  so  thai  the  card  contains  all  of  the 
important  points  which  might  be  desired  for  reference  a1  any 
future  time. 

When  the  patient  is  referred  from  one  department  to  an- 
other the  card,  according  to  this  system,  is  transferred  to  the  other 
department,  the  date  of  the  transfer  being  noted  upon  the  card. 
A  new  end  bearing  the  color  of  the  department  to  which  the  pa- 
tient has  been  referred  is  then  made  out  by  the  interne  in  such 
department;  and  this  card  should  contain  all  the  facts  of  card  B, 
together  with  any  additional  information  of  importance  which 
was  determined  by  the  department  to  which  the  patient  was  first 
referred,  and  which  had  been  noted  upon  the  card,  also  the  date 
on  which  the  patient  was  referred  and  the  name  of  the  department 
from  which  the  patient  was  received.    The  other  card  is  then  re- 


TiaaMosis 


lyOcA^Q 


!EL 


tsC^ 


Ao -erf  HisTuriy 

<36f~o 


q-mcl 


ss? 


-L^my, 


Ser.nce    JfDr      77/, l/t^      T^Jzl 


Krs.  3,0- o  ykzz*  /U 


CA^l 


hjy. 


!££ 


#M.W 


\Ll. 


Opt» 


Af^^/O.^tl 


/u 


i^  &  rn  ojt  \  s 


^L 


~>*Js- 


Kl  -/i~~  t>6 


rlu^c  17-  xo  - 


[4Z 


X3 


b^r-    LsJjS,    (AyM^LgJL    fll^t    ^xdefy    dtist*     <Ac<jU^ 


O'.rTVt  r\*  C 


/  y/-, 


Iyj1e-)-ne,      shms     T^L-C/l 


U^c^ped      X/-/Q-~    /9<?6 


AcUV.rted        /      Z  3  -     ifo  6 


"Skajj-fyz.  cJ-K3^4Lpc~  yi- 17-20 


n-tnyt^cj  T^#J!*.<jL     X  /  -  Q.  3  -  19 6(, 


Tfe.su  rtf, Jwstn/fsrfsK. f      )il \*.yno*\*     CJi^Jj^A, ',. 


(p*Zvk£<1  MAS  <?CU/.  ffl*g£s?/t,szst  /^t^  C^cUls  c&d 


3C 


OY^iei 


l.X  HIBIT  I). 

turned  to  the  preceding  department  and  filed  as  a  record  of  such 
department. 

This  system  provides,  first,  the  responsible  placing  of  each 
patient  so  thai  every  one  concerned  knows  to  whom  the  patient 
belongs;  second,  the  responsible  recording  oi  both  the  preliminary 
and  tho  final  diagnosis;  and,  third,  a  record  of  the  various  depart- 
ments in  which  the  patient  has  been  treated,  both  in  the  general 
records  and  in  those  of  each  individual  department. 

In  order  to  arrange  such  a  system  suitable  Tor  any  given  in- 
stitution it  is  well  for  the  staff  to  have  a  number  of  conferences 


FLANS  FOB    CHE  ASSIGNMENT  01     PATIENTS  77 

from  time  to  time,  because  what  would  answer  the  conditions  of 
one,  might  be  quite  out  of  proportion  for  another  similar  institu- 
tion. There  are  a  great  main  differences  regarding  the  relative 
number  of  patients  belonging  to  the  various  departments,  and  then 
there  are  further  individual  differences  regarding  the  plan  of 
management  of  the  various  individual  members  of  the  staff,  so 
that  it  is  impossible  to  draw  hard  and  fast  lines  which  would  apply 
alike  to  all  similar  undertakings  of  this  kind. 

It  is,  however,  always  important  to  develop  the  plans  sug- 
gested so  that  the  whole  organization  will  be  as  simple  as  possible, 
and  still  be  sufficiently  complete  to  eliminate  the  trouble  which 
must  come  from  every  imperfectly  organized  system. 

There  are  two  features  which  every  good  system  must  con- 
tain, and  which  are  incorporated  in  this  plan — viz.: 

First,  definite  lines  of  authority.  Every  member  of  the  staff 
knows  his  superior  and  inferior  officer;  he  is  responsible  in  his 
work  to  one  person,  and  those  under  him  are  responsible  alike  to 
him,  and  to  him  alone. 

Second,  no  one  without  experience  should  have  any  great  re- 
sponsibility; neither  should  his  duties  be  in  advance  of  his  position 
in  the  scale  of  development. 

These  principles  must  of  necessity  give  strength  to  an  institu- 
tion, and  they  must  also  establish  confidence  in  those  whose  support 
is  sought  for  the  work. 


CHAPTER  VI. 

DISCIPLINE  AND    RULES   GOVERNING  STALES. 

It  is  well  to  establish  all  of  the  minor  points  in  the  discipline 
of  the  house  staff  at  the  conferences  of  the  attending  staff,  at 
which  the  house  staff  is  present,  because,  as  a  rule,  the  members 
of  the  house  staff"  are  far  better  judges  of  such  matters  than  are  the 
members  of  the  attending  staff;  and  the  result  will  be  an  arrange- 
ment which  can  be  directly  applied  to  the  conditions  in  any  par- 
ticular. The  tact  that  it  has  been  virtually  approved  both  by  the 
attending  staff*  and  by  the  house  staff,  makes  it  practically  cer- 
tain that  the  point,  or  points,  agreed  upon  will  actually  be  car- 
ried out. 

Regulations  established  in  this  manner  have  a  fair  likelihood 
of  at  least  being  somewhat  reasonable,  which  is  never  the  case  if 
they  are  established  either  by  the  attending  staff,  or  any  one  of  the 
various  officers  of  the  institution. 

If  any  one  will  take  the  trouble  to  examine  the  printed  rules 
laid  down  in  most  hospitals  of  the  class  named,  and  will  apply  them 
to  the  conditions  existing  during  one's  personal  service  on  the 
resident  staff  of  the  hospital,  it  is  easy  to  see  the  hopelessness  of 
trying  to  live  up  to  such  rules.  In  time,  no  doubt,  certain  funda- 
mental rules  will  be  established  which  will  be  applicable  to  most  of 
these  institutions. 

The  following  rules   have  been  adapted  from  those  in  force 

in  one  of  the  largesl  and  most  important  hospitals  in  this  country: 

*  *  #  * 

RULES  FOR  RESIDENT  STAFF. 

The  resident  medical  staff  shall  consist  of  six  or  more  mem- 
bers, of  whom  the  resident  physician  and  the  resident  surgeon 
shall  be  resident  medical  officers  of  the  senior  grade,  and  the  resi- 
dent physician  for  special  diseases,  the  resident  pathologist,  the 
junior  resident  physician,  and  the  junior  resident  surgeon  shall 
be  resident  medical  officers  of  the  junior  grade.  They  shall  be 
appointed  on  aominations  made  by  the  medical  staff,  by  the  trus- 
tees of  the  hospital,  for  the  term  of  one  year. 

The   resident    medical   officers   of  the   senior  grade   shall    be 


DISCIPLINE  ANn   RULES   GOVERNING   STAFFS  79 

physicians  who  have  had  previous  experience  as  externe  and  junior 
officers  in  a  hospital  for  at  least  one  year.  They  shall  be  nomi- 
nated by  ballot  by  the  attending  medical  staff.  Resident  medical 
officers  of  the  junior  grade  shall  be  nominated  by  the  medical  staff 
from  a  list  established  by  a  competitive  examination,  conducted  by 
a  committee  of  the  medical  staff. 

Resident  medical  officers  of  the  senior  grade  shall  serve  for 
one  year  in  the  hospital,  for  two  periods  of  six  months,  as  the 
resident  physician  of  the  medical  division,  resident  surgeon  of 
the  first  surgical  division,  and  resident  surgeon  of  the  second  sur- 
gical division.  The  one  on  the  medical  side  serving  continuously 
as  medical  officer  of  his  department,  the  one  on  the  surgical  side 
serving  six  months  in  the  department  containing  patients  whose 
wounds  are  primarily  aseptic,  and  six  months  in  the  depart ment 
containing  wounds  which  are  primarily  not  aseptic.  The  service 
being  concluded  with  the  latter  service,  and  the  resident  surgeon 
occupying  the  latter  service  shall  be  known  as  the  first  resident 
surgeon,  ranking  above  resident  surgeon  occupying  the  former 
service,  who  shall  be  known  as  the  second  resident  surgeon. 

Resident  medical  officers  of  the  junior  grade  shall  serve  for  ODe 
year  divided  into  periods  of  three  months  each,  in  the  follow- 
ing positions:  Resident  physician  for  special  diseases,  resident 
pathologist,  junior  resident  physician,  and  junior  resident  surgeon. 
Members  of  the  resident  medical  staff  shall  elect  the  sequence  of 
their  service  in  order  of  seniority  of  appointment,  or  by  mutual 
consent.  A  sequence  of  service  once  established  should  not  be 
changed. 

For  the  purpose  of  establishing  the  terms  of  service  and  of 
defining  the  duties  of  the  resident  medical  staff,  the  following  three 
divisions  are  established : 

First — The  medical  division  shall  consist  of  the  general  medi- 
cal service,  the  special  departments  for  the  eye1,  ear,  aose,  throat, 
skin,  and  nervous  dieases.  This  division  shall  he  in  charge  of  the 
resident  physician,  and  the  junior  resident  physician. 

,  Second — The  first  surgical  division  shall  consist  of  all  sur- 
gical and  gynecological  patients  whoso  wounds  are  primarily  not 
aseptic.  This  division  shall  ho  in  charge  of  the  firsl  residenl  sur- 
geon and  the  junior  residenl  surgeon. 

Third — The  second  surgical  division  shall  consisl  of  the 
obstetrical  department,  and  of  all  surgical  and  gynecological  pa- 
tients whose  wounds  are  primarily  aseptic.  This  division  shall 
be  in  charge  of  the  second  resident  surgeon  and  the  second  junior 
resident  surgeon. 

The  resident  physician  shall  have  charge,  under  the  direction 


80  DISCIPLINE   AXD    RULES    GOYEBNING    STAFFS 

of  the  medical  staff,  of  the  medical  division  of  the  hospital.  He 
shall  examine  such  applicants  for  admission  to  the  hospital  as 
the  superintendent  may  direct,  and  report  to  the  superintendent 
the  nature  of  the  disease,  the  probability  of  the  relief  or  cure,  and 
the  division  of  the  hospital  to  which  the  patient  should  be  assigned. 
In  this  portion  of  his  service  he  shall  alternate  every  three  months 
with  the  first  senior  residenl  surgeon.  He  shall  register  his  diag- 
nosis upon  the  index  card.  He  shall  also  prepare  an  index  card 
in  the  proper  color  of  the  department  to  which  the  patient  has 
been  referred.  He  shall,  under  the  direction  of  the  attending  med- 
ical  staff,  recommend  to  the  superintendent  patients  for  discharge 
from  the  hospital,  and  enter  upon  the  clinical  histories  and  upon 
the  index  card  of  such  patients  a  summary  of  the  results  of  treat- 
ment and  the  condition  of  the  patient  on  leaving  the  hospital.  He 
shall  have  charge  of,  and  be  responsible  for,  all  clinical  histories 
and  other  medical  records  of  the  medical  department  of  the  hos- 
pital. He  shall  visit  each  patient  under  his  care  at  least  each 
morning  and  evening,  and  oftener  if  required,  and  shall  make  and 
record  a  physical  examination  of  every  case  under  his  charge 
within  twenty-four  hours  after  entrance,  unless  otherwise  directed, 
and  on  such  other  occasions  as  may  be  necessary.  He  shall  report 
to  each  member  of  the  attending  staff  the  admission  of  patients 
under  his  special  care.  He  shall  accompany  attending  physicians 
on  their  visits,  when  possible,  and  shall  report  the  state  of  each 
patient  and  the  treatment  each  has  received,  and  shall  see  that 
the  orders  of  the  attending  physicians  are  properly  executed.  He 
-hall  record  all  prescriptions  and  directions  for  treatment  on 
charts  provided  for  that  purpose.  He  shall,  at  stated  intervals, 
enter  upon  the  clinical  charts  a  summary  of  the  progress  of  the 
case  since  its  admission.  He  shall  compile  and  file  with  the  super- 
intendent of  the  hospital  the  monthly  statistical  report  of  cases  in 
the  hospital  during  the  preceding  month,  on  or  before  the  fifth 
day  of  each  month.  I!e  shall  assign  the  junior  resident  to  such 
other  work  in  the  medical  department,  not  specifically  described 
under  the  duties  of  a  junior  resident  physician,  as  seems  to  him 
to  be  necessary,  and  shall  himself  perform  such  other  work  within 
the  hospital,  not  specified  above,  as  may  be  assigned  him  by  the 
attending  physician. 

The  junior  resident  physician  shall  perform  the  duties  of  the 
senior  resident  physician  during  his  absence  or  temporary  dis- 
ability. He  shall  always  be  present  in  the  hospital  on  such  oc- 
casions. 

He  shall  obtain  and  record  the  history  and  an  examination 
of  the  urine  of  each  medical  case,  within  twenty-four  hours  after 


DISCIPLINE   AND    RULES   GOVERNING   STAFFS  81 

entrance  He  shall  make  all  chemical,  microscopical  and  bac- 
teriological examinations  which  may  be  required  in  the  medical 

division,  and  transcribe  the  results  of  each  examination  on  the 
clinical  charts.  He  shall  have  charge  of,  and  shall  keep  under 
lock  and  key,  the  electric  batteries,  immersion-lenses,  blood- 
counters  and  other  instruments  of  diagnosis,  excepl  the  microscope 
and  lower-power  lenses.  He  shall  give  these  instruments  to  the 
proper  persons  for  use,  but  shall  keep  note  of  the  same,  and  shall 
be  responsible  for  the  instruments.  He  shall  pass  the  catheter, 
when  necessary,  upon  the  male  medical  patients  and  shall  perform 
such  other  duties  in  the  medical  division  as  may  be  assigned  to 
him  by  the  attending  or  senior  resident  physicians. 

Each  resident  surgeon  shall  have  general  supervision  of  all 
patients  in  his  division  of  the  hospital.  He  shall  visit  each  pa- 
tient in  his  division,  at  least  every  morning  and  evening,  and 
oftener  when  required.  He  shall  record  all  prescriptions  and 
directions  for  treatment  in  charts  to  be  kept  for  that  purpose,  shall 
accompany  the  attending  surgeon  on  his  visits  through  his  division, 
and  shall  report  the  state  of  each  patient  to  the  attending  surgeon, 
and  the  treatment  each  one  has  received.  The  resident  surgeon 
shall  be  held  responsible  for  full  and  accurate  histories  of  every 
case  which  comes  under  his  professional  care,  lie  shall,  unless 
otherwise  directed  by  the  attending  surgeon  in  charge  of  the  pa- 
tient, make  a  complete  physical  examination  of  each  patient  and 
record  the  results  of  it  within  twenty-four  hours  a  tier  the  ad- 
mission of  the  patient.  He  shall  have  charge  of  such  surgical 
dressings  as  may  be  required  in  his  division,  and  shall  not  delegate 
their  performance  to  any  person  except  by  the  express  consent 
of  the  member  of  the  attending  staff  in  charge  of  the  patient.  He 
shall,  at  the  conclusion  of  each  surgical  dressing,  make  a  note 
in  the  clinical  record  of  the  patient,  stating  the  condition  of  the 
dressing  removed,  the  drainage,  if  any,  and  the  progress  of  heal- 
ing. He  may,  with  the  consent  of  the  member  of  the  attending 
staff  in  charge  of  the  patient,  direct  his  junior  resident  surgeon 
to  perform  such  duties  as  he  may  require,  lie  shall  assume  imme- 
diate charge  of  all  surgical  emergencies  arising  in  his  division  of 
the  hospital,  but  shall  not  give  general  anesthetics,  nor  undertake 
any  capital  operations  without  the  consent  of  a  member  of  the 
medical  staff.  He  shall  attend  all  operations  in  his  division,  as 
far  as  is  practicable,  and  be  ready  to  afford  such  assistance  and 
to  perform  such  other  duties  within  the  hospital  as  may  he  re- 
quired by  the  attending  surgeon,  lie  shall,  under  the  direction 
of  the  members  of  the  attending  medical  si-,\\]\  recommend  to  the 
superintendent  patients  for  discharge  from  the  hospital,  and  enter 


82  DISCIPLINE   AND   RULES   GOVEBNING    STAFFS 

upon  the  clinical  histories  of  such  patients  a  summary  stating  the 
results  of  treatment  and  the  condition  of  the  patient  on  leaving  the 
hospital.  He  shall  have  charge  of  and  he  responsible  for  all  clin- 
ical histories  and  other  medical  records  of  the  department  of  the 
hospital  under  his  charge. 

The  second  resident  surgeon  shall  render  such  assistance  in 
the  X-ray  department  of  the  hospital  as  may  be  required  of  him 
from  time  to  time. 

The  first  and  second  junior  resident  surgeons  shall  serve 
respectively  in  the  first  and  second  surgical  divisions  of  the  hos- 
pital. Each  shall  take,  transcribe  and  file  on  charts  provided  for 
the  purpose,  full  and  accurate  clinical  histories  and  the  result  of 
the  examination  of  urine  of  each  patient  admitted  to  his  division, 
within  twenty-four  hours  after  admittance,  unless  otherwise  di- 
rected by  the  attending  surgeon  m  charge  of  the  patient.  Each 
shall  make  all  chemical,  microscopical  and  bacteriological  examina- 
tions required  in  his  division,  without  delay,  and  transcribe  the 
results  of  such  examinations  on  the  clinical  charts  so  that  they  may 
be  made  available  in  treatment.  Each  shall  catheterize  all  male 
patients  in  his  division  when  that  service  is  required.  Each  shall 
act  as  anesthetist  in  all  operations  in  his  division,  in  so  far  as  is 
practicable,  under  the  supervision  of  the  official  anesthetist  of  the 
hospital.  Each  shall  perform  such  other  duties  in  his  division  as 
may  he  assigned  to  him  by  the  attending  surgical  staff  or  the 
resident  surgeons,  and  shall  alternate  with  the  other  in  responding 
to  ambulance  calls  in  the  absence  of  the  externe  acting  in  this  de- 
partment. 

The  externe  in  the  surgical  department  shall  have  charge  of 
the  ambulance  service  of  the  hospital  and  shall  see  that  all  regula- 
tions with  regard  to  the  same  are  enforced.  He  shall  act  as  anes- 
thetist under  the  supervision  of  the  official  anesthetist  of  the  hos- 
pital when  not  on  ambulance  duty,  and  he  shall  be  present  in  the 
operating  room  during  the  usual  hours  for  operations.  He  shall 
have  charge  of  the  patients  of  the  isolation  ward,  under  the 'di- 
rection of  the  attending  staff,  and  shall  take  and  lie  responsible 
for  all  these  clinical  histories.  He  -hall  perform  such  other  duties 
in  the  isolation  ward  as  are  prescribed  for  the  resident  surgeons 
in  their  respective  divisions.  He  may  be  temporarily  assigned  by 
tin-  attending  surgeon  to  such  other  duties  in  the  surgical  divisions 
as  the  necessities  of  the  service  may  require.  He  shall  assist  the 
junior  resident  surgeon,  and  be  responsible  to  him  in  the  per- 
formance of  his  duties. 

Members  of  the  resident  staff,  when  in  the  hospital,  are  at  all 
times  on  duty,  except  as  below  specified,  and  must  be  ready  and 


DISCIPLINE   AND   RULES   GOVERNING    STAFFS 


83 


willing  to  render  every  service  in  their  power.     Each  member  of 
the  resident  staff  shall  have  free  for  himself,  each  week  excluding 
Sunday,  one  afternoon  from  two  to  six  o'clock,  and  one  evening, 
from  seven  to  twelve  o'clock,  midnight.     During  these  hours  he  i> 
off  duty  and  may  be  away  from  the  hospital.    No  member  of  the 
resident  staff  shall  leave  the  hospital  at  any  other  time,  except 
on  ambulance  calls,  unless  he  has  the  written  permission  of  the 
superintendent.    In  addition  to  the  above  the  junior  resident  physi- 
cian and  the  externes  may  be  off  duty  during   Sunday    morning 
until  one  o'clock,  and  the  three  others  during  the  evening  from 
six  to  twelve  o'clock,  midnight,    The  terms  of  "off  duty"  for  each 
member  of  the  resident  medical  staff,  arranged  in  the  beginning 
of  each  new  service,  shall  be  published  as  a  bulletin  in  the  office  of 
the  resident  physicians  and  surgeons.    They  shall  at  each  change 
of  service  arrange  by  mutual  consent  or  by  lot,  for  their  respective 
terms  of  absence  from  the  hospital,  and  shall  each  observe  the 
rights  of  other  members.     One  member  of  each    division    shall 
always  be  present  in  the  hospital  unless  temporarily  absent  on 
ambulance  duty. 

Each  member  of  the  resident  stall'  shall  have,  during  each 
year  of  his  term  of  service,  not  more  than  three  weeks'  vacation, 
two  of  which  shall  be  during  the  months  ol'  .June,  July,  August  and 
September.  The  period  of  vacation  shall  be  determined  by  mutual 
agreement  among  the  members  of  the  resident  staff,  with  the  con- 
sent of  the  superintendent  and  the  members  of  the  attending  med- 
ical staff  in  whose  department  the  resident  officer  is  acting. 

When  any  member  of  the  resident  medical  staff  leaves  the 
hospital,  except  in  case  of  ambulance  calls,  he  shall  note  this  fad 
and  the  time  of  his  leaving  in  a  book  in  the  office  provided  for  that 
purpose,  and  he  shall  arrange  the  bulletin-board  so  that  the  word 
"out"  shall  be  opposite  his  name,  and  upon  returning  he  shall 
arrange  the  bulletin-board  so  that  the  word  "in"  will  appear  op- 
posite his  name.  It  shall  be  arranged  among  themselves  that  a 
majority  of  the  resident  staff  shall,  at  all  times,  be  in  (he  hospital 
unless  one  is  on  ambulance  duty.  Any  leave  of  absence  for  .1 
member  of  the  resident  medical  staff  for  a  longer  period  than  six 
hours  shall  be  in  writing  and  granted  only  by  the  superintendent, 
with  the  approval  of  the  members  of  the  attending  staff  then  on 
service  in  the  same  division,  after  provision  has  been  made  for 
the  proper  performance  of  the  duties  of  the  absentee. 

When  a  patient  comes  into  the  hospital  in  a  condition  of  im- 
mediate danger  of  death,  oi-  when  a  patient  already  in  the  hospital 
rapidly  sinks  into  a  dangerous  state,  the  residenl  physician  or 
surgeon  shall   inaugurate  such   treatment    a-   he  deems  necessary. 


84  DISCIPLINE   AND    RULES   GOVERNING   STAFFS 

and  shall,  as  soon  as  possible,  notify  the  attending  physician  or 
surgeon  of  the  condition  of  the  patient. 

A  female  nurse  shall  always  be  present  at  all  gynecological 
examinations;  none  such  shall  be  made  by  a  junior  resident  physi- 
cian or  surgeon,  except  by  the  direction  of  the  attending  physi- 
cian or  surgeon,  save  in  cases  of  danger  of  life. 

Members  of  the  resident  medical  staff  shall  follow  no  other 
business  or  practice  outside  of  the  hospital,  and  are  prohibited 
from  receiving  any  fee  from  any  person  whatever  for  any  service 
performed  for  any  patient  in  the  hospital. 

It  shall  be  the  duty  of  the  resident  staff  to  fill  out,  free  of 
charge,  all  death  and  birth  certificates,  insurance  affidavits  and 
other  necessary  medical  blanks  and  certificates  concerning  patients 
who  are  or  have  been  under  their  care. 

The  resident  staff  shall  be  called  at  —  A.  M.  Breakfast  shall 
be  served  only  from  —  to  —  A.  M.,  except  by  express  permission 
of  the  superintendent.  Each  resident  shall  commence  his  daily 
hospital  work  at  —  A.  M.,  or  earlier  if  necessary,  and  shall,  as 
far  as  possible,  complete  the  routine  hospital  work  before  —  A. 
M.  The  surgical  resident  staff  shall,  as  far  as  possible,  be  ready 
for  work  in  the  operating  room  by  —  A.  M. 

All  surgical  dressings  shall  be  made,  except  in  cases  of  emer- 
gency, during  the  day  tour  of  duty  of  nurses. 

The  resident  physician  and  the  resident  surgeon  shall  begin 
their  morning  visits  to  patients  at  promptly  —  o'clock,  and  their 
evening  visits  before  —  o'clock. 

All  catheterizations  of  all  patients  shall  be  done  by  members 
of  the  resident  staff. 

All  surgical  dressings  and  irrigations  for  male  patients  shall 
be  performed  by  members  of  the  resident  staff,  unless  the  member 
of  the  attending  staff  in  charge  of  the  patient  expressly  consents 
to  this  duty  being  performed  by  some  other  qualified  person. 

Examinations  of  the  heart,  lungs  and  urine  must  be  made  in 
every  case  prior  to  operation,  and  the  results  recorded  in  the  his- 
tory sheet. 

The  junior  resident  physicians  and  the  junior  resident  sur- 
geons shall  attend,  as  far  as  is  practicable,  all  autopsies  of  cases 
in  their  immediate  care,  and  enter  upon  the  clinical  histories  an 
abstract  of  the  pathological  diagnosis  and  the  immediate  cause 
of  death. 

No  member  of  the  resident  staff  shall  give  any  certificate  or 
statement  concerning  the  condition  of  any  patient  in  the  hospital, 
for  legal  or  other  purpose,  without  the  authority  of  the  attending 
physician  or  surgeon,  except  as  previously  provided. 


DISCIPLINE   AND   RULES   GOVERNING   STAFFS  85 

For  the  lack  of  professional  fidelity,  attention  or  skill,  or  of 
personal  courtesy,  any  member  of  the  resident  medical  staff  may. 
at  the  direction  of  an  attending  physician  or  surgeon,  be  suspended 
by  the  superintendent  from  duty  pending  final  action  by  the  board 
of  trustees  of  the  hospital. 

Should  any  member  of  the  resident  staff  feel  aggrieved  from 
any  cause  associated  with  his  work,  or  become  dissatisfied  with 
his  professional  assignments,  he  shall  state  in  writing  the  grounds 
for  his  dissatisfaction  to  the  secretary  of  the  attending  medicat 
staff,  who  shall,  upon  sufficient  notice  to  the  attending  medical 
staff,  give  a  hearing  to  all  parties  at  interest  and  decide  the  ques- 
tions involved  in  controversy.  An  appeal  from  this  decision  of  the 
attending  medical  staff  may  be  taken  to  the  board  of  trustees  for 
final  disposal. 

Members  of  the  resident  medical  staff  shall  substitute  for  each 
other  in  response  to  urgency  calls,  and  respond  cheerfully  to  all 
requests  of  the  superintendent  and  the  attending  medical  staff. 

To  each  member  of  the  resident  medical  staff  who  passes 
creditably  through  the  various  grades  of  the  service  there  shall 
be  given,  on  his  graduation,  a  diploma,  sigued  by  the  superin- 
tendent, the  president  and  secretary  of  the  board  of  trustees,  and 
the  medical  staff,  under  the  seat  of  the  corporation,  stating  the 
period  of  service. 

Members  of  the  resident  medical  staff  before  entering  upon 
their  duties,  shall  sign  a  statement  that  they  have  read  the  regu- 
lations and  that  they  will  faithfully  perform  their  duties  and  ob- 
serve the  rules  provided  for  them,  and  that  they  shall  be  under 
the  immediate  control  and  subject  to  the  orders  of  the  attending 
medical  staff,  and  shall  receive  no  diploma,  as  hereinbefore  pro- 
vided, unless  they  remain  the  full  term  of  service  to  which  they 
were  appointed,  and  discharge  their  duties  to  the  satisfaction  of 
the  attending  medical  staff,  the  superintendent  and  the  board  of 
trustees. 

When  for  any  reason  it  becomes  necessary  to  fill  a  vacancy  in 
the  resident  medical  staff,  the  appointee  shall  assume  the  sequence 
of  service  established  by  his  predecessor  and  shall  receive  a  cer- 
tificate stating  his  actual  service  in  the  hospital. 

#  *  * 

In  order  to  illustrate  the  manner  in  which  this  plan  <-,\n  be 
practically  applied  the  following  table  is  shown,  in  which  the 
letters  A.  B.  C.  T).  E.  E\  Gr.  stand  in  place  of  the  names  of  the 
members  of  the  resident  staff  on  duty  during  a  period  of  two  years. 
This  will  show  the  lime  each  member  spends  in  each  position; 
it  also  indicates  which  member  will  succeed  him  when  tins  period 


86  DISCIPLINE   AND   RULES   GOVERNING   STAFFS     . 

of  service  is  concluded.  It  also  shows  the  amount  of  preliminary 
training  each  member  has  had  before  he  acts  in  the  capacity  of 
senior  house  physician  or  surgeon. 

This  tabulation  does  not  show  the  service  of  externes  in  a 
hospital  of  two  hundred  active  beds. 

TYPICAL  ARRANGEMENT  OF  SCHEDULE  FOE  TWO 

YEARS'  SERVICE. 

A. — First  Senior  House  Surgeon's  Service,  begins  Jan.  1,  1906, 

ends  July  1,  1906.. 
B. — Second  Senior  House  Surgeon's  Service,  begins  Jan.  1,  1906, 

ends  July  1,  1906. 
B. — Becomes  First  Senior  House  Surgeon  July   1.   L906,  service 

ends  Jan.  1,  1907. 
C. — Senior  House  Physician  Service  begins  Jan.  1,  1906,  service 

ends  Jan.  1,  1907. 
D. — Pathologist  Service  begins  Jan.  1,  1906,  ends  April  1,  1906. 
I). — Becomes  Junior  House  Physician  Apr.  1,  1906,  service  ends 

July  1,  1906. 
D. — Becomes  Junior  House  Surgeon,  First   Division,  begins  July 

1,  1906,  service  ends  Oct.  1,  1906. 
D. — Becomes  House  Physician,  First  Division,  begins  Oct.  1,  1906, 

service  ends  Jan.  1,  1907. 
D. — May  become  Senior  House  Physician,  First  Division,  begins 

Jan.  1,  1907,  service  ends  Jan.  1,  1908. 
Or— 
Second  Senior  House   Surgeon,  begins  Jan.   1.    1907,   service 

ends  July  1,  1907. 
First  Senior  House  Surgeon,  begins  July  1,  1907,  service  ends 

Jan.  1,  1908. 
E. — Junior  House  Physician,  service  begins  Jan    1,  1900.  service 

.-lids  Apr.  1.  1906. 
E. —  Becomes  Junior  House  Surgeon.  First  Division,  begins  Apr. 

1,  1906,  service  ends  July  1.  1906. 
E. — Becomes  Special  House  Physician,  begins  July  1.  1906,  service 

ends  Oct.  1.  1906. 
K.     Becomes  Junior  House  Surgeon,  Second  Division,  begins  Oct. 

1,  1906,  service  ends  Jan.  1,   1907. 
E. — May  become — 

Either  Senior  House  Physician,  begins  Jan.  I.  1907,  service 

ends  Jan.  1,  1908. 
Or  Second  Senior  House  Surgeon,  begins  Jan.  1,  1907.  service 

ends  July  1.  1907. 


DISCIPLINE   A.TSK*  RULES   GOVERNING    STAFFS  »/ 

Or  First  Senior  House  Surgeon,  begins  July  1,  1907,  service 

ends  June  1,  1908. 
F—  Junior  House  Surgeon.  First  Division,  service  begins  Jan.  1, 

1906,  ends  Apr.  1,  1906. 
F.— Becomes  Special  House  Physician,  begins  Apr.  L,  l!>«i(i.  ends 

July  1,  1906. 
F_ Becomes  Pathologist,  service  begins  July   1.  1906,  ends  Oct. 

1,  1906. 
F._ Becomes  Junior  House  Physician,  service  begins  Oct.  1,  1906, 

ends  Jan.  1, 1907. 
Q._Special  House  Physician,   service  begins  Jan.    1,  1906,  ends 

Apr.  1,  1906. 
G.— Becomes  Pathologist,  service  begins  Apr.  1.  L906,  ends  July 

1,  1906. 
G.— Becomes  Junior  House  Physician,  service  begins  July  1,  1906, 

ends  Oct.  1,  1906. 
O.— Becomes  Junior  House  Surgeon,  service  begins  Oct.  1.  1906, 

ends  Jan.  1, 1907. 

It  is  profitable  to  have,  aside  from  this  resident  staff,  an  ex- 
terne  staff  which  is  distributed  according  to  the  activity  of  the  de- 
partment: each  resident  having  as  his  assistant  one  or  two  ex- 
ternes  who  serve  directly  under  him  and  Who  have  no  responsi- 
bility in  the  care  of  patients,  but  should  be  present  at  operations, 
assist  in  dressings  and  in  examinations,  and  make  themselves  use- 
ful in  any  way  desired  by  the  resident  staff. 

With  a  careful  system  of  selection  of  the  si  a  IT.  ami  a  reason- 
able arrangement  of  the  work  so  that  every  member  is  fully  occu- 
pied, there  need  be  no  occasion  for  the  occurrence  of  difficulties 
in  regulating  the  house  staff.  One  trouble  that  is  likely  to  come. 
however,  is  from  the  selection  of  internes  through  influence,  and 
not  through  merit;  the  natural  inference  of  the  interne  being  that 
so  long  as  it  was  not  necessary  to  excel  in  quality  in  order  to 
obtain  the  position,  it  is  not  necessary  to  excel  in  service  in  order 
to  maintain  his  position. 

The  second  source  of  trouble  arises  from  giving  internes  too 
little  work  to  do,  for  idleness  will  spoil  the  besl  internes. 

A  lark  of  regularity  and  punctuality  on  the  part  of  members  o1 
the  attending  staff  is  also  responsible  for  had  interne  service  in 
many  instances.  One  frequently  sees  excellent  internes  in  the 
department  of  one  attending  or  surgeon,  and  very  inferior  service 
in  the  department  of  another  member  of  the  attending  stall  oi  the 
same  institution,  not  because  there  is  a  difference  in  the  inherent 
quality  of  internes,  bul  because  the  member  of  the  attending  stall 
is  incompetent  in  some  particular. 


00  DISCIPLINE    AN  I  *  RULES    GOVEENIXG   STAFFS 

The  greatest  source  of  difficulty  in  managing  the  resident  staff 
at  the  present  time  in  the  majority  of  hospitals  organized  accord- 
ing to  the  plans  most  in  vogue  results  from  the  fact  that  there  are 
so  many  changes  that  no  definite  system  can  be  developed  at  any 
given  time  before  a  change  occurs  in  the  head  of  the  department. 
In  institutions  in  which  the  attending  physician  and  surgeon 
do  not  have  a  continuous  service,  so  that  there  are  changes  in 
each  department  every  two  to  six  months,  the  difference  in  the 
methods  and  in  the  personal  peculiarities  must  always  be  sufficient 
to  make  it  impossible  for  any  one  member  of  the  staff  to  perfect 
even  a  reasonably  fair  system  for  his  resident  staff. 

It  might  be  claimed  that  the  interruption  of  the  service  during 
the  vacation  of  the  chief  would  have  the  same  effect  in  the  system 
advocated  above.  This,  however,  is  not  the  case,  because  the  in- 
cumbent representing  the  chief  during  his  vacation  is  a  part  of 
the  latter 's  organization,  and  usually  has  had  his. early  training 
under  this  chief. 

In  smaller  institutions  of  fifty  beds  or  less  these  conditions 
naturally  become  still  less  favorable,  because  here  it  will  be  pos- 
sible to  maintain  only  one  resident  physician  or  interne,  and  he 
must  necessarily  serve  all  of  the  various  members  of  the  visiting 
staff. 

Usually  the  plan  of  securing  a  physician  for  this  position  who 
has  served  as  junior  resident  or  externe  in  some  larger  hospital, 
is  more  satisfactory  than  to  take  an  assistant  directly  from  some 
medical  school,  but  unless  he  be  a  young  man  with  unusual  tact, 
the  service  is  not  likely  to  be  very  satisfactory. 

Should  there  be  in  the  visiting  staff  one  person  whose  author- 
ity is  recognized  by  all  of  the  other  members  of  the  staff,  and 
whose  methods  are  followed  by  the  entire  staff,  this  member  must 
not  only  have  ability  to  arrange  the  service,  but  he  must  be  will- 
ing to  give  a  sufficient  amount  of  time  to  its  details  to  insure  its 
full  success.  It  is  from  this  side  of  the  organization  of  smaller 
hospitals  that  they  suffer  greatly  in  competition  with  the  larger 
ones.  On  the  other  hand,  this  very  fact  has  forced  many  physi-* 
cians  to  pay  special  attention  to  the  details  of  hospital  manage- 
ment for  these  smaller  institutions,  which  has  resulted  in  the 
establishment  of  many  splendidly  organized  small  hospitals  in 
various  parts  of  the  country. 

Where  the  hospital  is  still  smaller  the  difficulty  in  question  is 
overcome  in  another  manner.  Instead  of  employing  a  resident 
physician,  the  duties  which  are  ordinarily  performed  by  this  officer 
are  left  in  the  hands  of  the  superintendent  of  nurses.  With  care 
it  is  always  possible  to  secure  a  trained  nurse  with  great  execu- 


DISCIPLINE   AND   RULES   GOVERNING  STAFFS  89 

tive  ability,  good  judgment  and  extensive  experience,  who  can 
perform  these  duties  to  the  advantage  of  the  institution,  so  that 
the  service  is  vastly  better  than  it  would  be  under  the  care  of  a 
young  graduate  in  medicine. 

There  are  more  of  the  successful  small  hospitals  in  this  coun- 
try that  owe  their  usefulness  and  prosperity  to  the  energy,  tact 
and  judgment  of  a  carefully  selected  superintendent  of  nurses, 
than  to  any  other  one  factor  in  their  organization.  It  is  of  the 
greatest  importance  that  this  fact  be  borne  in  mind. 

GRADED  STAFF  FOR  MUNICIPAL  HOSPITALS. 

In  the  organization  of  large  municipal  hospitals  there  are  two 
chief  perils.  The  first  of  these  results  from  a  selection  of  entirely 
unfit  men  simply  through  political  influence.  The  second  follows 
from  selecting  men  whose  standing  is  sufficiently  high  when  they 
enter  upon  their  duties  to  warrant  their  appointment,  but  who 
fail  to  progress  because  they  are  secure  in  their  appointment  and 
the  element  of  competition  is  eliminated  from  their  sphere,  and 
without  this  stimulant  they  soon  fall  behind. 

In  this  manner  it  frequently  happens  that  the  development 
of  an  institution  is  greatly  hampered  because  the  principles  upon 
which  the  organization  is  planned  do  not  include  the  elements 
of  progress. 

This  fault  can  be  corrected  in  several  ways.  First,  by  an  age 
limit,  which  has  been  referred  to;  second,  by  a  service  which  is 
restricted  to  a  given  number  of  years;  and  third,  by  the  adoption 
of  a  graded  system  which  will  constantly  introduce  young  men  of 
unusual  ability,  training,  industry,  energy  and  enthusiasm. 

This  graded  system  will  make  it  impossible  for  incompetent 
novices  to  utilize  the  patients  of  the  institution  for  clinical  material 
for  their  own  advancement  without  regard  to  the  interests  of  the 
patients.  They  will  have  gained  great  experience  as  assistants 
before  they  are  placed  in  responsible  positions,  and  before  serious 
cases  have  to  depend  upon  their  unaided  judgment  for  decisions  of 
vital  importance.  It  will  be  worth  their  while  to  labor  diligently 
and  patiently  in  gaining  skill  and  learning,  because  the  system 
must  lead  ultimately  to  a  responsible  position  for  he  who  is  will- 
ing to  spend  his  time  and  energy  in  this  manner,  and  because  with 
a  service  that  is  limited  in  all  its  periods  vacancies  in  the  higher 
positions  are  bound  to  occur. 

It  seems  well  to  divide  this  service  into  five  periods  of  six- 
years  each,  as  follows:  The  first  period  should  he  composed  of 
two  parts  of  three  years  each;  the  first  three  years  should  be 
spent  in  the  capacity  of  externe,  junior  house  physician  or  sur- 


90  DISCIPLINE    AND    RULES    GOVERNING    STAFFS 

geon  or  both,  and  as  senior  house  physician  or  surgeon,  or  both; 
the  second  three  years  should  be  largely  spent  in  scientific  or  re- 
search work  either  at  home  or  abroad,  or  both,  and  service  in  the 
capacity  of  chief  clinical  assistant  to  the  chief  of  a  department  or 
to  a  visiting  physician  or  surgeon. 

The  second  period  of  sis  years  should  be  spent  as  junior  at- 
tending physician  or  surgeon,  and  in  the  service  of  attending  physi- 
cian or  surgeon  to  the  outdoor  or  dispensary  department.  Much 
time  should  be  spent  in  diagnosis,  and  research  work  should  be 
continued. 

The  third  period  of  six  years  should  be  given  as  attending  or 
visiting  physician  or  surgeon,  having  charge  of  certain  wards  un- 
der the  direction  of  the  chief  of  the  department. 

The  fourth  period  of  six  years  should  be  occupied  as  chief  of 
a  department  in  full  control  of  entire  division  of  the  hospital.  It 
is  possible  that  this  period  should  be  twice  as  long  as  each  of  the 
other  periods,  in  order  to  make  it  worth  while  to  spend  years  of 
hard  labor  for  the  purpose  of  achieving  this  position,  and  in  order 
to  provide  a  sufficiently  long  service  to  enable  an  incumbent  to 
complete  extensive  plans  of  development. 

In  order  to  secure  the  best  results  in  this  class  of  institutions, 
there  can  be  no  doubt  that  the  period  of  this  service  should  be 
definitely  fixed. 

The  fifth  period  should  be  indefinite.  The  incumbent  should 
be  eligible  to  this  position  only  after  completing  the  fourth  period. 
This  office  should  carry  no  responsibilities  and  no  duties.  It 
should,  however,  contain  all  the  privileges  of  all  the  other  mem- 
bers of  the  staff,  all  of  whom  having  the  right  to  request,  but  not 
to  demand,  the  advice  of  any  member  of  the  consulting  staff. 

In  smaller  cities  not  exceeding  twenty-five  thousand  inhab- 
itants the  question  of  organizing  a  hospital  staff  is  especially  dif- 
ficult. 

It  is  equally  difficult  to  lay  down  rules,  because  an  examination 
of  existing  conditions  shows  that  wherever  these  institutions  have 
been  successful,  the  success  could  be  attributed  to  the  fact  that  the 
institution  contained  one  physician  or  surgeon  of  unusual  quali- 
fications. These  qualifications  may  be  largely  personal,  without 
unusual  skill  or  learning,  or  there  may  be  a  rare  combination  of 
several  of  the  important  requisites,  such  as  attractive  personality, 
reliability,  judgment,  tact,  energy,  industry,  perseverance,  pa- 
tience, and  hopefulness,  together  with  learning,  experience  and 
professional  skill. 

It  is  doubtful  whether  it  will  be  possible  to  formulate  a  system 
which  can  be  applied  to  the  circumstances  existing  in  most  of  the 


DISCIPLINE   AND;  RULES   GOVERNING   STAFFS  91 

smaller  towns,  but  for  the  present  the  following  two  plans  have 
afforded  the  best  results: 

The  first  plan  has  been  adopted  in  many  of  the  hospitals  con- 
ducted by  the  sisterhoods. 

The  hospital  is  open  to  any  reputable  physician  so  long  as  he 
does  not  use  his  influence  to  oppose  the  interests  of  the  institution. 
This  has  the  advantage  of  leaving  the  government  of  the  institu- 
tion entirely  in  the  hands  of  a  person  who  has  an  opportunity  to 
study  hospital  management,  and  one  whoso  whole  interest  is  di- 
rected toward  the  advancement  of  the  institution.  This  person  is 
the  sister-in-charge  of  the  hospital.  She  soon  Learns  from  ob- 
servation which  physicians  or  surgeons  in  the  city  are  thoroughly 
interested  in  hospital  work,  and  then  she  can  go  to  such  for  advice. 

A  further  advantage  of  affording  every  practitioner  in  the  city 
an  opportunity  to  treat  any  patient  he  desires  in  the  hospital  with- 
out regard  to  specialties,  is  allowed. 

The  disadvantage  in  this  system  comes  from  the  fact  that  it 
does  not  provide  for  a  reasonable  working  machine  from  the  stand- 
point of  the  medical  department,  and  although  the  results  are 
usually  fairly  good,  they  can  never  attain  any  real  excellence. 

The  second  plan  implies  a  division  into  the  various  special- 
ties. In  very  small  hospitals  the  entire  field  may  be  divided  into 
medical  and  surgical. 

Whatever  the  number  of  specialties  may  be,  each  member  of 
the  staff  must  confine  his  activity  within  the  hospital  to  his  spe- 
cialty, and  he  must  also  spend  a  reasonable  amount  of  time  each 
year  in  post-graduate  work  for  the  purpose  of  becoming  more  ex- 
pert in  his  special  department. 

Aside  from  this  difference,  the  organization  of  the  medical 
staff  should  be  the  same  as  in  case  of  larger  hospitals  conducted 
by  hospital  societies. 

It  may  be  well  to  limit  the  executive  or  attending  staff  to  one 
person  for  each  specialty,  and  to  appoint  all  of  the  other  physi- 
cians in  the  city  who  are  willing  to  he  active  in  the  development  of 
the  institution  to  the  visiting  staff,  with  the  same  privileges,  but 
with  the  omission  of  executive  duties. 

This  course  is  likely  to  he  beneficial  to  the  institution  by 
obtaining  the  support  of  the  entire  local  medical  profession. 


CHAPTER  VII. 

ORGANIZATION  OF  TRAINING  SCHOOLS. 

The  first  and  most  important  point  to  be  considered  in  connec- 
tion with  the  organization  of  training  schools  for  nurses  is  to  secure 
a  proper  person  for  the  head  of  this  department.  While  it  is  often 
difficult  to  accomplish  this  object,  yet  in  this  country  it  is  always 
possible.  If  all  irrelevant  conditions  are  ignored,  and  a  person  is 
chosen  because  she  possesses  the  necessary  personal  qualities,  the 
necessary  education  and  experience,  the  patience,  perseverance, 
reliability,  industry  and  executive  ability  required  for  the  position, 
and  above  all  an  unlimited  amount  of  enthusiasm  for  her  work, 
then  the  first  and  most  important  step  has  been  taken.  In  many 
instances  other  qualifications  are  placed  first,  and  the  requisites 
mentioned  above  are  placed  only  in  a  secondary  position. 

When  a  person  is  chosen  because  of  her  religious  denomina- 
tional convictions,  nationality  or  because  of  some  social  qualifica- 
tion, the  result  is  nothing  short  of  a  calamity,  as  it  virtually  elim- 
inates the  element  of  competition  throusrh  merit. 

In  selecting  a  person  to  fill  the  position  of  Superintendent  of 
Nurses,  it  is  important  to  place  much  value  upon  actual  experience. 
It  is  far  better  to  choose  a  nurse  who  has  acted  as  superintendent 
in  a  training  school  in  a  small  hospital,  or  as  assistant  superin- 
tendent in  a  large  one,  or  as  head  nurse  of  a  floor,  pavilion  or  de- 
partment in  a  la  rue  hospital,  than  to  select  a  recent  graduate,  how- 
ever brilliant  her  attainments  may  be,  who  has  not  had  any  actual 
experience  in  a  similar  capacity.  It  is  the  actual  experience  which 
enables  a  Superintendent  of  Nurses  to  determine  what  can  be  ac- 
complished with  existing  conditions  in  the  institution  to  which 
she  may  be  called  (for  the  purpose  of  acting  as  superintendent  of 
the  training  school). 

Taking  it  for  granted  thai  a  poison  with  (he  proper  qualifica- 
tions has  boon  chosen,  the  department  should  be  entirely  under  her 
direction.  She  should  arrange  the  course  of  study,  the  number  of 
lectures,  recitations  and  examinations.  She  should  pass  upon  quali- 
fications for  admission,  and  should  have  power  to  dismiss  pupil 
nurses  for  any  reason  that  might  seem  proper  to  her. 

In  case  the  service  of  a  nurse  is  unsatisfactory  to  the  mem- 


ORGANIZATION    OF   TRAINING   SCHOOLS  93 

bers  of  the  staff,  their  criticism  should  be  made  to  the  Superin- 
tendent of  the  Training  School,  whose  duty  it  would  be  to  devise 
means  to  make  the  nursing  satisfactory. 

In  hospitals  of  more  than  fifty  beds  an  Assistant  Superin- 
tendent of  Nurses  should  be  employed,  who  should  be  chosen  by 
the  Superintendent  of  Nurses  and  appointed  by  the  Board  of 
Trustees.  In  hospitals  of  more  than  one  hundred  and  fifty  beds, 
there  should  always  be  a  night  superintendent  of  nurses,  who 
should  also  be  chosen  by  the  Superintendent  of  Nurses,  and  ap- 
pointed by  the  Board  of  Trustees. 

TRAINING  OF  NURSES. 

In  order  that  the  training  may  be  efficient  and  the  services 
of  the  nurse  at  the  same  time  satisfactory  to  the  hospital,  it  is 
important  that  the  Superintendent  of  Nurses  be  in  constant  con- 
tact with  her  pupil  nurses  throughout  the  entire  term  of  service. 
It  is  impossible  to  give  nurses  proper  training  in  the  classroom 
alone,  or  by  an  occasional  tour  of  inspection  through  the  hospital. 
The  scientific  teaching  by  means  of  lectures  must  be  supplemented 
every  day  and  all  day  by  friendly  assistance  at  the  bedside.  The 
training  given  to  nurses  should  so  develop  women  with  the  neces- 
sary qualities  as  to  enable  them  to  care  for  the  sick  properly,  not 
only  in  the  hospital,  but  also  in  private  families;  consequently  a 
nurse  must  acquire  many  qualities  outside  of  those  necessary  to 
enable  her  to  perform  the  technical  work  connected  with  her  pro- 
fession. 

The  Superintendent  should  be  with  her  pupil  nurses  at  the 
nurses'  home,  in  the  dining  room,  at  their  recreation,  and  should 
use  her  influence  and  enthusiasm  to  direct  and  further  their  de- 
velopment. 

It  is  important  that  there  be  no  friction  in  the  management  of 
the  training  school.  This  can  be  accomplished  if  the  nurses  learn 
from  experience  that  merit  alone  counts,  and  that  the  authority  of 
their  Superintendent  is  absolute,  and  al  the  same  time  just  and 
competent.  It  is  necessary  to  teach  the  pupil  nurse  by  example, 
not  precept.  There  must  he  concentration  in  all  the  work  done, 
whether  this  be  in  study  or  in  bedside  nursing.  This  affects  the 
success  of  the  institution  enormously.  The  result  in  the  training 
of  the  individual  nurse  is  of  the  very  greatest  value. 

It  is  doubtful  if  there  is  much  to  he  gained  by  malting  the 
course  ultra-scientific  in  its  tendency.  In  a  general  way  a  nurse 
with  good  judgment  eannot  have  too  much  learning  unless  it  be 
acquired  at  the  expense  of  practical  knowledge.  The  nurse's 
service  in  the  hospital  during  her  term  as  pupil  nurse  must  nee- 


94  ORGANIZATION    OF   TRAINING   SCHOOLS 

essarily  be  largely  practical,  and  it  is  what  she  actually  does  for 
the  patient  that  most  benefits  the  institution  as  well  as  herself. 
In  payment  for  this  service  to  the  institution  she  receives  her  sci- 
entific training.  After  graduation  her  services  in  the  capacity  of 
private  nurse  are  practical  in  character;  it  is  consequently  im- 
portant that  this  side  of  her  training  should  receive  careful  atten- 
tion. 

The  conduct  of  a  training  school  in  a  hospital  lias  the  imme- 
diate object  of  furnishing  the  Lnstitutiton  with  competent  nursing 
within  the  means  of  the  institution.  Remotely  the  character  of  the 
nurses  graduated  affects  the  institution  to  a  great  extent,  because 
those  rmrses  reflect  the  quality  of  their  training  during  their  work 
a-  private  nurses  in  the  families  of  people  whose  interest  is  val- 
uable to  the  institution. 

In  some  of  the  smaller  cities  it  seems  proper  for  the  hospital 
to  furnish  a  certain  number  of  pupil  nurses  for  service  in  families 
whose  financial  condition  prevents  them  from  employing  trained 
or  graduate  nurses.  But  there  is  a  possibility  of  abuse  in  this 
direction,  and  it  is  never  well  to  make  a  commercial  institution 
out  of  a  training  school  for  nurses.  In  larger  cities  where  the 
visiting  nnrses  associations  are  established,  it  is  probably  best 
to  prohibit  under-graduate  nurses  from  doing  private  nursing 
while  they  are  still  in  training  in  the  hospital. 

SIZE   OF  HOSPITALS  REQUIRING  TRAINING  SCHOOLS. 

At  the  present  time  there  is  a  tendency  to  oppose  the  estab- 
lishment of  training  schools  in  small  hospitals.  The  training  is 
undoubtedly  not  so  varied  in  these  smaller  institutions,  where  only 
a  limited  variety  of  diseases  are  treated.  The  nursing  of  surgical 
patients  usually  predominates,  there  are  but  few  medical  cases 
and  no  obstetrical  patients.  After  graduation,  however,  these  two 
varieties  of  patients  furnish  almost  the  entire  work  for  the  grad- 
uate trained  nurse..  From  an  educational  standpoint  there  are 
objections  against  the  training  of  nurses  in  these  smaller  hospitals, 
but  the  deficiency  in  training  can  be  supplemented  after  gradua- 
tion by  the  members  of  the  staff,  who  usually  employ  these  nurses 
in  their  private  practice,  which  is  largely  composed  of  obstetrical 
and  medical  cases.  In  a  general  way  a  competent  surgical  nurse 
can  easily  be  changed  into  a  safe  and  efficient  obstetrical  nurse, 
consequently,  viewed  from  its  practical  side,  there  seems  to  be  no 
serious  objection  against  the  establishment  of  training  schools  in 
small  hospital-. 

The  real  objections  to  this  plan  are,  first,  that  it  is  difficult  to 
obtain  for  the  position  of  Superintendent   in  a  small  institution 


ORGANIZATION   OF   TRAINING   SCHOOLS  95 

a  nurse  competent  to  conduct  a  training  school ;  and,  second,  that 
members  of  the  staff  so  often  do  not  appreciate  the  importance 
of  being  systematic  in  their  lectures  to  the  nurses.  In  order  to 
avoid  this  last  difficulty  the  Superintendent  of  Nurses  should  ar- 
range a  schedule  of  lectures  to  be  given  at  different  hours  on  dif- 
ferent days  of  the  week.  Each  member  of  the  teaching  sta if  should 
also  be  a  member  of  the  medical  staff  of  the  hospital.  He  should 
have  assigned  to  him  a  definite  hour  on  definite  days,  upon  a  reg- 
ular schedule.  In  smaller  towns  it  is  difficult  for  members  of  the 
staff  to  be  free  at  a  given  time,  because  of  the  emergencies  that 
occur  in  the  professional  life  of  these  practitioners.  In  order  to 
avoid  a  part  of  this  difficulty  in  the  management  of  the  curriculum 
of  the  training  school,  the  following  plan  has  been  employed:  The 
members  of  the  teaching  staff  arrange  a  syllabus  of  each  lecture 
upon  a  card  before  the  beginning  of  the  term  of  instruction.  A.1 
each  lesson  they  may  enlarge  or  supplant  this  syllabus,  but  they 
must  have  an  outline  of  the  entire  course  completed  at  the  begin- 
ning of  the  school  year.  This  card  system  must  be  so  arranged 
that  each  lecture  is  a  unit  in  itself. 

The  Superintendent  of  Nurses  has  a  list  of  the  teachers  on 
duty,  and  in  case  one  of  these  teachers  is  prevented  from  filling 
his  hour  as  per  schedule,  he  should  notify  the  Superintendent  of 
Nurses  of  this  fact  and  she  in  turn  should  communicate  with  the 
next  member  of  the  staff  on  her  list  and  secure  his  services  for  tin- 
horn1. If  he  should  also  find  it  impossible  to  fill  the  hour,  each 
successive  member  of  the  teaching  staff  is  communicated  with 
until  one  that  is  available  is  found.  Having  previously  arranged 
the  outline  for  his  lecture,  it  will  be  possible  for  him  to  fill  the  hour 
without  special  preparation,  and  without  detriment  to  the  course. 
It  is  exceedingly  harmful  to  the  discipline  of  a  class  to  dismiss  it 
because  a  teacher  fails  to  fill  an  hour  according  to  schedule.  In 
case  a  member  of  the  staff  fails  repeatedly  to  keep  his  teaching 
engagements,  another  of  the  staff  should  be  permanently  substi- 
tuted in  his  place. 

Another  difficulty  in  connection  with  the  didactic  instruction 
of  nurses  comes  from  the  fact  thai  they  are  occasionally  prevented 
from  appearing  in  class  because  of  some  emergency  that  keeps 
them  with  the  patients.  In  order  not  <<>  let  this  elemenl  discour 
age  the  pupil  nurse,  the  teacher  should  briefly  review  the  sub 
stance  of  the  previous  lecture.  It  is  also  well  to  have  the  pupil 
nurses  work  in  pairs,  each  one  taking  careful  notes  of  the  lecture 
and  supplying  these  notes  i<>  the  classmate  who  happens  to  be 
detained  by  her  duties  from  attending  the  lecture. 

It  is  important,  however,  to  ^tate  here  thai  with  proper  plan- 


96  ORGANIZATION    OF   TRAINING  SCHOOLS 

ning  on  the  part  of  the  Superintendent  of  Nurses,  it  will  be  almost 
always  possible  for  the  nurses  to  be  present  at  every  lecture,  bi 
order  to  accomplish  this  the  Superintendent  must  keep  an  ac- 
curate list  of  nurses  belonging  to  the  various  classes  which  meet 
at  a  definite  hour  on  different  days  of  the  week.  Every  morning 
in  giving  the  special  orders  of  service  for  the  day,  the  Superin- 
tendent of  Nurses,  or  her  assistant,  should  assign  substitute  duty 
for  the  nurse  who  cannot  leave  her  work  for  the  hour  in  question. 
It  will  be  necessary  to  keep  a  number  of  relict'  nurses  for  this  pur- 
pose, which  will  vary  according  to  the  severity  of  the  cases  under 
treatment  in  the  hospital.  The  service  is  improved  so  greatly  by 
the  introduction  of  this  element  that  the  additional  expense  of  pro- 
viding these  relief  nurses  is  of  no  importance.  To  allow  frequent 
absence  from  class  work  speaks  of  incompetence  or  carelessness 
on  the  part  of  the  head  of  the  training  school. 

ADMISSION  OF  PUPILS  TO  THE  TRAINING  bCEOOL. 

Until  recently  most  training  schools  accepted  pupils  at  any 
time  during  the  year  under  the  supposition  that  it  would  not  be 
well  to  have  a  large  proportion  of  the  nurses  leave  the  hospital  at 
one  time,  and  consequently  their  places  taken  by  new  nurses,  or 
"beginners."  It  seems,  however,  that  this  supposition  is  not 
borne  out  by  recent  experience.  By  receiving  all  of  the  pupil 
nurses  for  a  given  year  at  the  same  time,  or  by  receiving  one-half 
of  the  number  at  one  time  and  the  other  half  six  months  later,  it 
is  possible  to  train  all  of  these  nurses  in  the  elements  of  their 
profession  uniformly.  It  is  true  that  this  imposes  an  additional 
burden  on  the  older  nurses  for  a  time,  but  this  is  counteracted  by 
the  fact  that  all  the  pupils  progress  more  uniformly  in  their  the- 
oretical and  practical  education  than  they  would  if  the  training 
school  contained  pupils  in  all  stages  of  development;  furthermore, 
each  nurse  will  receive  the  benefit  of  every  detail  in  the  training. 

QUALIFICATIONS  FOR  ADMISSION. 

There  must  necessarily  be  an  educational  qualification,  which 
will  vary  with  the  location  of  the  training  school.  The  pupil  nurse 
must  have  a  sufficient  amount  of  preliminary  education  to  be  able 
to  comprehend  the  various  studies  contained  in  the  curriculum. 
Ordinarily  it  is  probably  best  to  require  the  equivalent  of  an  ordi- 
aary  high  school  education.  The  applicant  should  be  physically 
st  rong  in  order  to  perform  the  arduous  tasks  required  of  her.  She 
should  be  at  least  twenty  years  of  age,  and  under  thirty-five  years; 
she  should  possess  kindliness  and  refinement,  and  she  should  be 
fully  imbued  with  the  seriousness  of  her  purpose  and  of  her  work. 


ORGANIZATION    OF   TRAINING  SCHOOLS  97 

Possessing  these  qualities,  it  seems  unnecessary  to  add  that  she 
must  be  honest.  Lacking  in  honesty,  she  would  be  absolutely  dis- 
qualified for  this  work. 

TERM  OF  SERVICE  FOR  NURSES. 

As  regards  the  length  of  the  course  great  injustice  can  be 
done  by  retaining  the  nurse  three  years,  practically  offering  the 
third  year  what  was  given  during  the  first.  In  the  larger  hospitals 
having  departments  of  internal  medicine,  snrgery  and  obstetrics, 
as  well  as  various  minor  departments,  it  is  probably  best  to  have 
the  term  of  service  for  nurses  three  years.  In  the  smaller  hos- 
pitals it  is  better  to  have  the  service  two  years,  the  nurse  then 
taking  a  post-graduate  course  of  one  year. 

ARRANGEMENT  OF  INSTRUCTION. 

The  course  should  always  be  graded,  a  definite  service  being 
outlined  for  each  class. 

The  laboratory  instructions,  lectures  on  medical  diseases,  sur- 
gical technique  and  obstetrics  are  given  by  the  medical  staff,  while 
the  other  instruction  is  given  by  the  Superintendent  and  her 
assistants. 

The  junior  nurses  are  given  the  general  ward  duties;  the 
intermediate  class  receive  the  laboratory,  diet-kitchen  ..-ad  special 
duty  service;  the  senior  class  is  given  the  operating  room,  the 
obstetrical,  and  head  nurse  service.  During  the  first  months  clin- 
ical demonstrations  are  given  to  probationers  in  sections  of  eight 
or  ten.  A  uniformity  in  method  is  thus  at  once  established,  and 
an  opportunity  afforded  the  instructor  to  judge  of  the  pupil's 
adaptability. 

SUBJECTS. 
First  Clinic — 

Introductory  talks  on  the  cause  and  danger  of  infection. 

Disinfection.    . 

Care  of  all  bedside  utensils  with  disinfection  and  steril- 
ization. 

Care  of  the  lavatory. 

Care  of  typhoid  excreta. 

Care  of  soiled  linen. 
Second  Clinic — 

('are  of  beds;    iron,  brass,  folding. 

Care  of  mattresses — hair,  straw,  water,  air. 

Care  and  protection  of  pillows,  bed  covers. 

Cleaning  of  bedsteads  and  mattresses     renovating. 

Prevention  and  extermination  of  vermin. 


98  ORGANIZATION    OF    TRAINING   SCHOOLS 

Making  beds  for  convalescents. 

Making  beds  for  bed  patients. 

Making  beds  for  operation  cases. 
Third  Clinic — 

( 'arc  of  bed  patients. 

Batli>. 

( Jleansing. 

Shampooing. 

Changing  position. 

( 'hanging  clothing. 

Lifting. 

Appliances,  pads,  rings,  cradles,  hot  bags,  bottles,  bricks, 
head  rests,  foot  rests. 
/■'mirth  ( 'linic — ■ 

Pulse. 

Temperature. 

Respiration  in  health  and  disease. 

( 'are  of  the  mouth. 

Care  of  the  hands. 

(  'are  of  the  back. 

Feeding  helpless  patients. 
Fifth  Clinic — 

Sponging. 

Packing. 

Tubbing. 

Ice  bags,  caps  and  coils. 

Cold  com i tresses. 

Medicated  baths. 

Hot  air  baths. 

<  Jalomel  fumigations. 
Sixth  Clinic — 

Fomentations  and  turpentine  stupes. 

Poultice-. 

Plasters. 

Blisters. 

( !ounter-irritants. 

Cupping. 

Leaches. 

Antiphlogistic-. 
Seven tli  Clinic — 

Sterilization. 

Hand-     instruments. 

1  dressings. 

Surgical  supplies  for  bedside  dressings. 


ORGANIZATION    or   TRAINING   SCHOOLS  99 

Eighth  Clinic — 

Enemata — nutritive,   sedative,  stimulating,  laxative. 

Catheterization. 

Douches — vaginal  and  vesical. 
Ninth  Clinic — 

Gastric  lavage. 

Nasal  feeding. 

Hypodermoc  lysis. 

Hypodermic  injection. 
Tenth  Clinic — 

Charting. 

Recording. 

Procuring  specimens— urine,  feces,  stomach  contents. 

Preparation  of  patient  for  an  operation. 
Eleventh  Clinic — 

Bandaging. 

Fractures. 

Fracture  beds. 

Improvising  splints — stretchers. 

Gynecological  positions. 

Local  applications. 
Twelfth  Clinic — 

Medicines. 

Weights  and  measures. 

Correct  labeling. 

Care  in  dispensing. 

Methods  of  administration. 

Making  of  solutions. 

Giving  oxygen. 

Simultaneously  with  the  nursing  clinics,  these  instructions  in 
nursing  ethics  and  etiquette  are  given  : 
Nursing  Ethics — 

Nursing  history. 

Qualifications. 

The  spirit  of  nursing. 

Discipline. 

Health. 

Study. 

Economy. 

Courtesy,  sympathy. 

Uniform. 

The  patient,  the  doctor,  the  friends. 

Ward  (lutv. 


100  ORGANIZATION    OF   TRAINING   SCHOOLS 

Night  duty. 
Special  duty. 
Administrative  duties. 
The  graduate  nurse. 

Junior  Year — 

Elementary  physiology. 

Bacteriology. 

Hygiene. 

Elementary  materia  medica. 

Medical  diseases. 

Cooking  classes. 
Intermediate  Year — 

Physiology  and  anatomy. 

Advanced  materia  medica. 

Dietetics. 

\  rrinalysis. 

Anesthetics. 

Surgical  technique. 

Gynecology. 
Senior  Year — 

Obstetrics. 

Pediatrics. 

Private  duty. 

Training  school  executive  work. 

Parliamentary  law. 

Preparation  for  Alumna?  Association. 

Discussions  of  nursing  journal  articles. 

NUMBER  OF  NURSES. 

The  character  of  the  medical  and  surgical  work  in  each  hos- 
pital will  determine  the  number  of  nurses  required.  If  there  are 
many  cases  of  chronic  diseases  treated  in  the  hospital  one  nurse 
will  probably  suffice  for  every  five  patients.  If  the  service  is  lim- 
ited to  acute  cases,  it  will  require  at  least  one  nurse  for  every  three 
beds.  In  children's  hospitals  where,  only  acute  cases  are  taken,  it 
will  require  one  nurse  for  every  four  beds;  if  chronic  cases  pre- 
dominate, one  nurse  for  six  or  eight  beds  will  be  sufficient. 

GRADUATE  NURSES  IN  HOSPITALS. 

In  the  large  institutions  it  has  been  found  advantageous  to 
employ  a  number  of  recently  graduated  nurses  for  the  most  im- 
portant positions — for  head  nurse  of  the  operating  room,  and  for 
a  nurse  in  charge  of  each  of  the  various  pavilions  or  floors  in  the 


ORGANIZATION    OF   TRAINING   SCHOOLS  1<»1 

many-storied  hospitals.  In  hospitals  which  are  divided  into  de- 
partments, with  a  member  of  the  medical  staff  at  the  head  of  each 
department,  it  is  best  to  have  a  graduate  head  nurse  for  each  de- 
partment, so  that  this  nurse  can  be  directly  responsible  to  the  head 
of  the  medical  staff,  being  at  the  same  time  under  the  super- 
vision of  the  Superintendent  and  Assistant  Superintendent  of 
Nurses. 

A  number  of  small  institutions  have  attempted  to  secure  un- 
usually excellent  nursing  by  employing  only  graduate  nurses.     If 
this  is  done  according  to  a  definite  system  which  establishes  the 
nursing  department  of  the  private  hospital  as  a  post-graduate 
training  school  for  the  care  of  private  patients,  it  may  be  fairly 
satisfactory,  providing  the  course  continues  for  a  period  of  at 
least  six  months,  and  is  under  the  rigorous  supervision  of  a  head 
nurse  of  superior  qualifications.    If,  however,  each  nurse  is  em- 
ployed for  the  individual  case  that  is  under  treatment,  the  result 
will  be  most  unsatisfactory,  as  it  will  be  impossible  to  establish 
discipline.     These  nurses  cannot  be  all  taken  from  one   school, 
consequently  there  can  be  no  uniformity  in  their  service.     During 
the  short  period  they  are  employed  in  the  hospital  they  cannot 
become  familiar  with  the  system  preferred  by  the  Superintendent 
in  charge.     Were  it  possible  to  employ  graduate  nurses,  and  to 
keep  each  of  these  nurses  for  six  months,  or  a  year,  or  longer,  it 
would  still  be  doubtful  whether  the  nursing  as  a  whole  would  be 
as  satisfactory  as  it  is  in  institutions  supplied  with  under-grad- 
uate  nurses.     The  service  requiring  special  skill  can  be  carried 
out  by  those  who  have  been  in  training  sufficiently  long  to  be  per- 
fectly competent,  and  the  remaining  service  can  be  accomplished 
by  those  less  thoroughly  tmined  if  there  is  careful   supervision 
of  their  work.    The  earnest,  constant  endeavor  and  the  enthusiasm 
one  finds  among  under-graduate  nurses  adds  much  to  the  value  of 
their  services,  and  is  a  strong  element  in  favor  of  the  training 
schools,  in  preference  to  the  work  done  by  post-graduate  nurses. 


THE  CONSTRUCTION 
OF  HOSPITALS. 


INTRODUCTION. 

The  ever  increasing  demand  for  Hospitals  has  given  rise  to  a 
problem  the  solution  of  which  is  of  serious  and  vital  importance, 
and  which  up  to  the  present  time  has  been  neither  definitely  nor 
comprehensively  determined.  More  than  in  any  other  class  of 
building  the  hospital  architect,  the  expert  in  this  particular  and 
specific  branch  of  architecture,  realizes  that  in  his  work  he  must 
anticipate  progress.  Most  hospitals  are  built  too  quickly,  and 
therefore  imperfectly,  and  in  consequence  the  present  only  is  con- 
sidered, without  serious  thought  for  the  future.  The  architect  is 
too  often  dominated  by  the  hospital  committee  in  the  matter  of  size 
and  expenditure,  irrespective  of  the  relative  bearing  of  one  upon 
the  other.  In  its  eagerness  to  complete  a  structure,  a  committee 
will  often  voluntarily  sacrifice  the  best  and  accept  an  imperfect 
plan.  Instead  of  slowly  and  carefully  perfecting  a  good  plan, 
which  should  be  carried  out  as  circumstances  permit,  it  deliberate- 
ly foregoes  what  it  knows  is  ideal.  In  this  the  committee  is  not  the 
only  transgressor  as  the  architect  should  not  permit  himself  to  be 
a  party  to  any  such  proceeding. 

One  well-planned,  perfectly  built  hospital  is  more  to  be  de- 
sired than  many  that  have  been  conceived  with  the  predominant 
thought  of  a  building  to  serve  a  purpose,  and  in  which  there  has 
been  no  provision  whatever  for  the  future. 

The  hospital  architect  of  to-day  must  exercise  care  in  design- 
ing his  building  along  lines  not  as  the  committee  wishes  it  to  be 
planned,  but  rather  along  those  which  will  give  to  it  whal  is  really 
needed  for  its  future  development. 

Hospital  architecture  is  only  in  its  infancy.  The  evolution  has 
but  begun;  modern  appliances  and  methods  of  construction;  the 
application  of  aseptic  principles;  the  multitude  of  ever-increasing 
methods,  must  be  closely  followed  and  used  intelligently  to  the  end 
that  all  hospitals  shall  be  the  best  to  serve  their  purpose  now  and 
in  the  future. 


CHAPTER  VIII. 

GENERAL  CONSTRUCTION. 

It  will  not  be  necessary  to  go  into  the  detail  of  construction  of 
buildings  of  this  character,  as  the  general  rules  and  specifications 
which  are  employed  in  the  erection  of  any  building  would  apply 
here  also.  It  will,  however,  be  necessary  to  go  into  detail  regard- 
ing special  materials  that  are  better  adapted  for  hospitals  than  any 
other  material  would  be  for  this  purpose. 

There  is  probably  no  class  of  building  for  which  a  responsible 
contractor  is  so  necessary  as  in  hospitals,  as  so  much  depends  upon 
the  sanitary  condition  of  the  building  itself.  It  must  be  well  erect- 
ed in  all  its  essential  parts  in  order  that  everything  may  tit  prop- 
erly, and  that  there  shall  be  no  cause  whatever  for  extraordinary 
effort  in  keeping  the  institution  in  a  good  condition.  This  particu- 
larly applies  to  interior  construction. 

Another  point  to  be  taken  into  consideration  is  the  fact  that 
irresponsible  contractors  are  frequently  given  the  work  because 
they  have  underbid  some  responsible  man,  or  because  some  favor- 
itism is  shown.  Often  the  committee  or  some  inexperienced  mem- 
ber superintends  the  work  without  consulting  the  architect.  Con- 
sequently there  are  serious  defects,  which  make  the  difference  be- 
tween a  good  piece  of  work  and  one  which  is  imperfect. 

The  specifying  of  material  should  be  left  to  the  expert  (the 
architect  who  specializes  on  hospital  work),  for  he  keeps  in  touch 
with  the  newest  and  best  improvements  and  is  qualified  to  deter- 
mine what  should  be  used.  All  matters  pertaining  to  the  construc- 
tion of  the  building  should  be  referred  to  the  architect.  No  changes 
should  he  sanctioned  or  permitted  by  any  one  except  upon  written 
order  of  the  architect.  There  is  no  more  potent  factor  for  dissen- 
tion  and  consequent  errors  than  the  promiscuous  orders  of  mem- 
bers  of  committees  to  permit  changes  and  substitution  of  material; 
once  this  is  begun  the  contractors  set  at  naught  all  orders  of  the 
architect  and  there  immediately  arise  the  defects  mentioned. 

In  the  designing  of  buildings  for  hospital  purposes  the  one 
essential  feature  always  to  be  kept  in  mind  is  that  the  best  results 
are  to  be  obtained,  namely  : 

The  maximum  of  efficiency  at  a  minimum  cost.    A  building  of 


GENERAL   CONSTRUCTION  107 

this  character  should  under  no  circumstances  whatever  be  a  monu- 
ment to  either  the  committee  which  is  in  charge  of  the  building  nor 
to  the  architect  who  is  doing  the  work.  A  specialist  appreciates 
this*,  for  he  well  knows  that  a  sightly  and  well  constructed  building 
can  be  erected  at  a  cost  which  will  make  a  decided  saving  over  the 
more  ornamental  design,  and  that  this  difference  in  cost  will  often 
pay  for  the  entire  equipment  of  the  institution 

The  architect  must  differentiate  between  construction  as  i  s 
sential  and  as  accessory  in  erecting  buildings  of  this  character.  By 
essential,  is  meant  those  things  which  are  absolutely  necessary  in 
the  construction  of  the  building'.  By  accessory  is  meant  such 
things  as  are  not  necessarily  structural,  hut  which  still  make  a  dif- 
ference between  a  complete,  well  constructed  institution  and  one  in 
which  small  faults  are  evident.  As  an  example  of  this  principle 
are  the  partitions  which  make  the  stair  well  and  elevator  shaft  fire- 
proof and  isola-ted.  Attention  may  also  be  called  to  the  fact  that 
while  wooden  window  sills  might  fulfill  all  requirements  as  an  ac- 
cessory, they  are  still  not  necessary  as  an  essential,  for  a  splay 
can  be  put  at  the  sill  and  do  away  entirely  with  the  ordinary  (lat 
sill;  but  as  an  accessory  the  wooden  sill  is  not  the  best  material 
that  can  be  used  for  very  obvious  reasons,  such  as  their  destruct- 
ibility,  the  necessity  for  keeping  them  painted  and  varnished  vo 
prevent  their  discoloration  and  deterioration  ;  sills  of  marble,  slat;1, 
or  even  of  glass  while  still  accessory  are  highly  essential. 

As  stated  elsewhere,  it  is  not  the  object  of  the  authors  to  offer 
general  suggestions  for  the  construction  of  hospitals,  as  this  is  ob- 
viously the  province  of  the  supervising-  architect,  or  the  local  archi- 
tect as  the  case  may  be.  Nor  are  the  suggestions  made  here  to  be 
considered  as  being  the  outline  of  specifications,  for  it  will  be  nec- 
essary to  treat  the  topic  heads  in  different  specifications  in  exact 
manner,  not  only  generally  but  to  fit  local  conditions.  'The  salient 
features,  those  necessary  in  hospital  construction,  are  set  forth  as 
to  the  best  possible  method  of  treating  the  various  parts  of  the 
work.  It  will  be  found  that  there  are  many  items  herein  omitted. 
which  the  architect,  in  making  his  specifications,  will  undoubtedly 
be  able  to  supply,  as  they  are  standard  in  all  classes  of  buildings 
and  in  many  cases  are  fundamental. 

A  hospital  building  must  be  constructed  properly.  IT  there 
are  not  sufficient  funds  at  hand  to  do  this,  the  entire  project  should 
be  delayed  until  there  are,  or  until  it  is  assured  thai  money  will  be 
forthcoming.  'The  plans  should  be  thoughtfully  and  carefully 
considered,  so  that  the  money  at  hand  can  be  employed  |o  the  best 
advantage.  It  Ls  not  necessary  primarily  to  have  a  given  amount 
of  money    to    produce   a    desired    result.      It    is    far   better   to    have 


108  GENERAL   CONSTRUCTION 

plans  drawn  and  thoroughly  discussed,  and  all  of  the  details  Left 
in  the  hands  of  an  expert  and  gone  over  with  the  committee  before 
the  building  is  started.  The  initial  expense  of  plans  and  specifica- 
tions is  nil  where  time  is  concerned.  The  only  loss  after  the  build- 
ing is  started  is  in  the  structure  advancing  slowly;  when  once 
started,  it  should  be  carried  to  its  completion  as  quickly  as  possi- 
ble without  changes  of  any  sort,  and  this  is  possible  only  when  the 
plans  and  specifications  are  complete  in  every  detail.  The  em- 
ployment of  an  architect  who  has  had  experience  and  is  conversant 
with  these  details  of  hospital  construction  is  the  logical  means  to 
such  an  end. 

In  the  construction  of  hospitals  what  is  absolutely  essential 
for  the  stability  and  protection  of  the  building,  as  well  as  for  the 
safety  of  the  contents  and  occupants,  is  too  often  proscribed 
owing  to  the  short-sighted  views  of  economy.  That  fireproof  con- 
struction is  to-day  one  of  the  most  valuable  assets  in  building  can- 
not be  denied.  If  we  consider,  as  we  should,  that  hospitals  are 
built  for  all  time,  a  small  increase  of  expenditure  at  the  beginning 
should  not  stand  in  the  way.  It  would  be  better  policy  to  curtail 
cost  in  other  directions  rather  than  to  cut  down  on  so  vital  a  point 
as  fireproofing.  A  building  so  constructed,  even  with  the  plainest 
exterior  and  simpler  interior  finish,  is  vastly  preferable  to  one 
with  an  ornate  front  and  interior  construction,  which,  at  best, 
would  not  be  permanent  and  which  could  be  so  easily  destroyed. 

It  is  the  duty  of  the  architect,  therefore,  first  and  foremost, 
to  insist  upon  thorough  fireproof  construction.  When  one  con- 
siders that  the  actual  difference  in  cost  between  a  so-called  slow- 
burning  mill  construction  and  a  fireproof  building  is  ten  per  cent, 
in  the  heaviest  and  largest  building,  and  that  in  hospitals  this 
rarely  exceeds  five  per  cent.,  it  needs  no  great  amount  of  argu- 
ment in  favor  of  the  latter  form  of  construction.  Added  to  this  is 
the  moral  obligation  on  the  part  of  the  hospital  authorities  to  safe- 
guard, by  all  possible  means,  the  lives  of  the  patients.  As  hos- 
pitals are  essentially  erected  for  the  saving  of  lives,  every  possi- 
ble means  at  hand  must  be  employed  to  this  end,  and  the  safe- 
guarding of  those  who  are  helpless,  by  placing  them  in  buildings 
which  are  immune  from  fire,  should  not  be  the  least  or  last  of  these 
precautions.  On  the  contrary,  it  is  the  first  requisite  that  the 
construction  of  the  hospital  should  be  absolutely  fireproof  in  every 
detail. 

It  is  the  intention  to  give  herein,  as  concisely  as  possible,  what 
is  essential  under  given  circumstances,  how  this  can  best  be  pro- 
cured, and  how  the  maximum  results  in  both  the  matter  of  build- 
ing and  the  running  of  the  institution  after  being  built  can  be  ob- 


GENERAL    CONSTRUCTION 


109 


tained.  Under  separate  headings  the  essentials  of  good  construc- 
tion for  modern  hospitals  will  be  given  in  detail,  especially  those 
points  which  are  at  present  unobtainable,  except  through  very- 
tedious  and  more  or  less  dubious  channels,  for  the  use  of  the  indi- 
vidual or  committee  building  a  hospital. 

The  modern  methods  of  fireproofing,  and  the  general  con- 
struction of  buildings  necessitated  by  this,  will  be  found  under  a 
separate  head. 

It  mus.t  be  borne  in  mind  at  all  times  that  superfluous  orna- 
ment bears  no  organic  relation  to  the  hospital  itself.  Esthetics 
may  have  great  influence  upon  the  design  of  a  building  of  this 
character.  The  exterior  of  a  building  may  be  made  to  serve  as 
a  monument  to  the  man  who  furnished  the  funds ;  to  the  architect 
who  has  highly  esthetic  ideas  and  a  lack  of  practical  application 
to  the  real  problems  confronting  him,  but  to  the  average  man 
interested  in  this  problem  it  is  evident  that  the  best  working  re- 
sults obtainable  must  be  procured  for  the  money  in  hand. 

Dr.  Goldwater  says  "The  hospital  of  1870 — I  mean  the  aver- 
age hospital— was  built  at  a  cost  of  about  fifteen  cents  per  cubic 
foot.  The  exterior  was  simple;  the  plumbing  and  heating  were 
of  a  kind  now  considered  rudimentary;  the  building  was  not  fire- 
proof, and  was  finished  with  wood  and  with  plaster  on  lath.  Such 
a  hospital  could  be  duplicated  in  New  York  to-day,  if  the  building 
laws  allowed,  at  a  cost  of  twenty  cents  a  cubic  foot.  Allowing  for 
all  purposes  six  thousand  cubic  feet  per  patient  (an  unusually 
liberal  allowance,  for  1870),  the  cost  of  a  hospital  of  450  beds  or 
2,700,000  cubic  feet  would  be  $540,000,  or  $1,200  per  bed. 

"Now  compare  with  this  the  most  recently  constructed  gen- 
eral hospital  in  New  York  City,  a  hospital  built  to  accommodate 
four  hundred  and  fifty  patients.  This  building  or  group  of  build- 
ings at  the  prevailing  market  rates  for  construction  would  cost 
forty  cents  per  cubic  foot.  (The  actual  cost  was  nearer  thirty-five 
cents  per  foot,  but  the  contract  was  made  at  a  moment  favorable 
for  the  hospital  and  could  hardty  be  duplicated  to-day.)  If  the  old 
space  allowance  prevailed — namely,  six  thousand  cubic  feet  per 
patient — a  modern  hospital  of  four  hundred  and  lil'tv  beds  would 
cost  just  double  the  price  of  brick  and  wood  hospital  of  the  kind 
I  have  described— that  is,  $2,400  per  bed  instead  of  $1,200. 

(iCost  of  foreign  hospitals.  It  may  add  to  the  interesl  of  the 
argument,  but  it  will  not  help  much,  to  compare  with  these  figures 
the  costs  of  certain  typical  foreign  hospitals,  some  of  thein  not 
so  recently  built,  but  all  ranking  as  modern.  In  Germany  under 
quite  different  economic  conditions  and  with  a  simpler  type  of 
construction,  costs  have  been  relatively  low.     The  Ifamlmrg-Ep- 


1  ID  GENERAL    CONSTRUCTION 

pendorf  Krankenhajis,  built  nearly  twenty  years  ago  for  1,500 
patients,  cosl  3,480  marks,  or  $870  per  bed;  the  Municipal  Hos- 
pital in  Berlin,  known  as  the  Urban  Krankenhaus,  which  accom- 
modates six  hundred  patients,  cost  $1,075  per  bed,  and  'Fried- 
erichshain,'  under  the  same  management,  cost  $1,500  per  bed.  To 
turn  to  France,  it  may  be  noticed  that  the  Larisboisiere,  Pig.  294, 
a  monumental  pavilion  hospital  built  in  Paris  about  sixty  years 
ago  and  accommodating  about  six  hundred  patients,  cost  $3,250 
per  bed, 

"St.  Thomas'  Hospital  in  London  has  accommodations  for 
558  patients,  and  its  cost  of  construction  was  about  the  same.  The 
costliest  hospital  in  London  is  the  Belgrave  Hospital  for  children, 
built  for  seventy-eight  patients  at  a  cost  of  $3,500  per  bed.  The 
Royal  Victoria,  at  Belfast,  on  the  other  hand,  presents  an  example 
of  a  recently  constructed  hospital,  embracing  seventeen  large 
wards  and  costing  only  $1,500  per  bed." 

One  of  the  leading  physicians  and  a  superintendent  of  one  of 
the  largest  hospitals  in  New  York  recently  stated  that  in  the  analy- 
sis of  increased  cost  he  takes  as  the  units  which  have  contributed 
to  this  cost  the  difference  in  material;  the  greater  space  allow- 
ance per  patient;  protection  against  fire — that  is,  the  substitution 
i»r  fireproof  instead  of  inflammable  building  materials;  the  intro- 
duction of  complicated  heating  and  ventilating  plants;  automatic 
heat  regulation;  the  use  of  electric  light  and  power;  the  water 
supply  ;  the  equipment  of  laundry,  refrigeration,  kitchens  and  diet 
kitchens;  the  ward  unity;  the  introduction  of  dressing  rooms, 
anesthetizing  rooms,  sterilizing  rooms,  etc.,  with  the  surgical  de- 
partment; the  matter  of  disinfection  and  sterilization;  the  con- 
sulting rooms;  the  housing  of  the  house  staff;  taking  care  of  the 
nursing  force,  and  the  accommodation  of  the  minor  employes; 
the  introduction  of  special  departments,  such  as  the  X-ray  depart- 
ment and  hydrotherapeutic  department;  the  use  in  some  hospitals 
of  the  outdoor  department— the  isolation  wards  and  the  branch 
hospitals  for  convalescents;  all  of  which  subjects  will  be  treated 
separately  under  their  respective  heads,  but  are  mentioned  here 
to  -how  some  of  the  items  that  are  responsible  for  the  increased 
cosl  of  hospital  construction. 


CHAPTER  IX. 

LOCATION  OF  HOSPITALS. 

The  location  of  a  hospital  .should  be  chosen  in  order  to  secure 
the  following  conditions : 

First — An  abundance  of  sunlight. 

Second — Absence  of  noise. 

Third — Absence  of  dust. 

Fourth — Absence  of  smoke. 

Fifth — Proper  ventilation. 

Sixth — Disposition  of  sewage.  _ 

Seventh — Safety  from  fire. 

Eighth — Possibility  of  future  expansion. 

Ninth — Accessibility  for  patients,  their  friends  and  for  the 
medical  staff. 

Investigation  regarding  the  location  of  existing  hospitals  will 
show  that  in  most  instances  they  were  not  chosen  because  of  the 
above  considerations.  Ordinarily  it  will  be  found  that  the  hospital 
location  is  chosen  because  it  is  cheap;  because  some  philanthropic 
person  has  donated  it  to  the  committee;  because  some  influential 
member  wishes  to  dispose  of  a  particular  piece  of  property;  be- 
cause it  is  in  the  vicinity  of  some  medical  college;  or  because  some 
selfish  member  of  the  medical  stall'  desires  the  hospital  convenient 
to  his  residence;  and  only  rarely  because  it  is  especially  suited  for 
a  hospital  site. 

There  are  certain  fundamental  principles  which  should  be 
borne  in  mind  in  the  selection  of  a  site  for  a  hospital,  no  matter 
whether  it  be  located  in  a  great  city  or  a  country  town.  ( M'  course 
all  conditions  are  only  relative.  It  is  but  rarely  possible  to  obtain 
the  ideal  conditions  in  the  selection  of  a  site,  which  have  indeed 
been  practically  obtained  in  a  few  instances,  one  particular  exam- 
ple being  that  of  the  Royal  Victoria  Hospital,  in  Montreal;  but  it  is 
possible  in  every  city  or  town  to  approximate  these  conditions 
much  more  closely  than  has  been  done  in  90  per  cent  of  all  hospi- 
tals. It  should  be  stated  here  that  this  criticism  applies,  to  a  less 
extent,  to  the  institutions  conducted  by  sisterhoods  than  any 
others,  because  their  selection  of  sites  has  in  many  cases  been 
based  upon  the  following  principles. 


1.12 


LOCATION    OF   HOSPITALS 


ABIWDAXCK  OF  SUNLIGHT. 

It  is  so  extremely  simple  to  plan  a  building-  so  that  every  room 
and  ward  will  have  sunlight  during  .some  portion  of  the  day  that  it 
is  surprising  to  find  many  hospital  buildings  in  which  one-third  or 
more  of  the  rooms  never  have  a  ray  of  sunlight. 

In  order  to  have  sunlight  in  each  room  and  ward  it  is  neces- 
sary only  to  construct  all   buildings  or  pavilions  from    north  to 


FIG.   1. 

Meyer   J.    Sturm,   Architect. 

south,  which  will  give  one  long  side  sunlight  in  the  morning  and 
the  other  side  in  the  afternoon. 

The   importance  of  sunlight,  its  distribution,  the  production 
and  depth  of  shadows,  together  with  the  bearing  this  subject  has 


LOCATION    OF    HOSPITALS 


113 


upon  the  planning  of  hospitals,  has  been  studied  and  illustrated 
with,  great  care  by  Wm.  Atkinson,  architect.  The  author  has  kind- 
ly consented  to  permit  the  use  of  his  article,  and  as  it  has  been 


found  impossible  to  improve  upon  it,  it  will  be  inserted  in  full  in 
connection  with  the  discussion  of  ground  plans.  The  various 
shapes  of  wings  have  been  thoroughly  discussed  in  this  article  with 


114  LOCATION    OF    HOSPITALS 

a  careful  consideration  of  the  amount  of  sunlight  and  shadow  ob- 
tained by  buildings  of  the  various  forms  usually  employed. 

At  this  point  it  may  be  well  to  direct  attention  to  the  fact  that 
in  long  wings  with  a  central  hall,  with  wards  or  rooms  arranged  on 
either  side  of  the  hall,  two  outside  and  two  inside  walls,  will  house 
as  many  patients  as  four  outside  and  two  inside  walls  would  were 
tiio  wards  or  rooms  arranged  alongside  one  outside  wall  and  a  hall 
placed  along  the  other  outside  wall  and  separated  from  the  wards 
or  rooms  by  an  inside  wall.  This  is  plainly  illustrated  in  Figs.  1 
and  2.  which  represent  two  typical  plans:  Fig.  1  represents  a  hos- 
pital extending  from  aorth  to  south  in  which  every  room  or  ward 
is  exposed  to  sunlight  either  in  the  forenoon  or  afternoon  and  the 
hall  during  midday;  Fig.  2  represents  a  building  extending  from 
east  to  west  with  all  of  the  rooms  and  wards  exposed  to  the  suu 
from  the  south  and  with  a  hall  extending  along  the  northern  wall. 

It  is  plain  that  the  expense  of  constructing  a  hospital  for  a 
given  number  of  beds  must  be  at  least  60  per  cent,  greater  if  plau 
Fig.  2  is  followed  than  with  plan  Fig.  1,  because  the  additional 
walls  amount  to  50  per  cent,  and  there  will  be  required  double  the 
amount  of  outside  walls  which  are.  of  course,  much  more  expen- 
sive. Moreover  the  same  area  of  hall  space  serves  twice  the  num- 
ber of  beds  in  Fig.  1  that  it  serves  in  Fig.  2. 

Bui  this  is  not  all;  the  distance  ol  travel  required  by  those  em- 
ployed in  caring  for  the  sick  is  just  doubled.  The  area  of  the  hall 
which  must  be  kept  clean  is  twice  as  great.  The  number  of  win- 
dows which  must  be  kept  clean  is  approximately  twice  as  great. 

Aside  from  this  there  is  the  disadvantage  in  plan  2  from  the 
fact  that  twice  the  surface  of  outside  wall  is  exposed  to  the 
weather  and  twice  the  amount  of  hall  space  must  be  heated. 

Against  this  we  have  the  fact  that  in  plan  Fig.  2  every  room 
is  exposed  to  the  south.  In  most  climates  it  is  likely  that  exposure 
to  sunlight  for  half  the  day  is  equally  satisfactory  in  all  except  the 
mmmer  season,  and  to  be  preferred  in  this  season. 

it  seems  plain  consequently. thai  plan  Pig.  1  is  much  to  be  pre- 
ferred. 

ABSENCE  OF   NOISE. 

The  site  should  be  in  a  quiel  portion  of  the  <-it\  or  town,  away 
from  noisy  railroad  tracks,  street  cars  or  elevated  railroads,  or 
noisy  factories.  In  country  towns  ihis  can  be  accomplished  easily, 
and  in  great  cities  the  location  can  be  chosen  at  least  three  blocks 
away  from  ordinary  railroad  tracks. 

(Nine-tenths  of  all  of  the  larger  hospitals  in  most  of  the 
American  cities  are  located  directly  upon  one  or  two  street  car 
tracks  or  within  two  blocks  of  an  ordinary  railroad  track.) 


LOCATION  OF  HOSPITALS  1  1  5 

ABSENCE  OF  DUS  I  . 

The  location  should  be  so  chosen  as  to  reduce  exposure  to 
street  dust  to  a  minimum.  This  can  besl  be  accomplished  by  -  • 
lecting  a  high  knoll  in  a  hilly  town,  or  by  setting  the  building  back 
from  the  street  a  considerable  distance  in  a  flat  city  and  planting 
trees  and  shrubs  which  will  acl  as  natural  filters  along  the  edge  of 
the  grounds  along  the  streets,  and  by  erecting  high  buildings. 
Very  little  street  dust,  relatively,  rises  above  the  second  story,  -  i 
that  the  higher  stories  are  nearly  free  from  this  contamination.  In 
every  city  there  are  streets  which  are  comparatively  little  used. 
This  fact  should  be  considered  in  the  selection  of  a  hospital  site. 

FREEDOM    FROM    SMOKE. 

In  many  of  our  great  cities  there  are  locations  in  which  there 
is  but  rarely  any  sunshine  because  of  the  presence  of  coal  smoke 
from  large  furnaces  and  factories.  These  locations  should  of 
course  he  avoided  in  selecting  hospital  sites. 

It  is  well  to  note  the  general  direction  of  winds  and  to  hear  in 
mind  the  fact  that  smoke,  although  very  diffusible  in  the  air,  will 
not  be  distributed  to  any  considerable  extent  againsi  even  the 
slightest  current  i«i  the  air.  It  is  also  important  to  bear  in  mind 
that  when  the  air  is  apparently  still  it  nevertheless  travels  at  a 
rate  of  about  one  hundred  feet  per  minute,  oi  about  as  one  would 
move  in  sauntering  along  the  street,  taking  a  step  in  two  seconds. 

Again,  in  protecting  the  institution  against  smoke  from  any 
given  source  one  can  obtain  a  fair  idea  of  the  entire  amount  that 
will  be  delivered  to  an  institution  in  still  air  by  taking  the  distance 
from  that  source  as  the  radius  of  a  circle  oi  which  the  segment 
corresponding  to  the  length  of  the  institution  indicates  the  rela- 
tive proportion  of  the  smoke  carried  to  this  distance  which  will  be 
delivered  to  the  institution. 

This  illustration  is  employed  to  show  how  little  of  the  entire 
volume  of  smoke  will  be  delivered  in  still  air  to  any  given  space 
which  may  be  occupied  by  I  lie  hospital ;  and  if  the  location  is  wiselj 
chosen  with  this  point  in  view  it  is  usually  possible  to  have  the  hos 
pita!  on  the  windward  side  of  the  sources  of  especially  great  smoke 
producers  during  the  prevailing  winds,  and  thus  the  smoke  nuis 
ance  will  not  be  so  much  of  an  annoyance  as  one  might  expect. 
Fortunately  smoke  is  usually  produced  in  certain  center.-,  and 
these  centers  can  be  avoided  to  a  ven  considerable  extent  l»\  the 
careful  selection  of  the  site. 

VIXTI  LA  HON. 

It  is  plain  that  the  location  of  a  building  will  affect  the  condi- 
tions of  ventilation  to  a  very  marked  extent  and  that  buildings   lo- 


116  LOCATION    OF    HOSPITALS 

cated  upon  an  elevation  will  be  consantly  exposed  to  a  more  rapid 
current  of  air  than  they  would  be  were  they  situated  at  a  low  point, 
especially  if  the  low  point  is  surrounded  by  other  high  buildings. 
Locating  on  the  high  points  would  favor  natural  ventilation,  and 
in  case  forced  ventilation  was  employed,  it  would  be  possible  to 
obtain  air  of  much  greater  purity  to  force  into  the  wards  and 
rooms  of  hospitals. 

If  the  city  is  built  upon  a  fiat  area,  groat  advantage  can  be  ob- 
tained as  regards  ventilation  by  placing  the  hospital  to  the  leeward 
side  of  a  park,  or  a  body  of  water,  in  order  to  have  the  side  from 
which  currents  of  air  approach  during  the  greater  portion  of  the 
year  as  nearly  as  possible  unobstructed. 

SEWERAGE. 

In  large  cities  the  matter  of  sewerage  is  usually  so  well  ar- 
ranged that  little  difficulty  is  experienced  from  this  source,  no  mat- 
ter where  the  hospital  is  situated. 

In  smaller  cities,  in  which  there  is  no  perfect  system,  it  is  im- 
portant to  give  the  subject  careful  attention,  especially  since  there 
is  greater  danger  of  contamination  in  hospitals  than  in  other  kinds 
of  buildings. 

SAFETY   FROM    FIRE. 

In  communities  in  which  most  of  the  buildings  are  constructed 
of  wood  it  is  well  to  select  a  location  as  far  as  possible  removed 
from  other  buildings.  This  will  prevent  a  panic  among  patients  in 
case  of  fire  in  the  neighborhood.  Even  in  a  perfectly  fireproof  hos- 
pital, with  no  actual  danger  of  direct  contact  with  fire,  the  risk  of  a 
panic  is  of  sufficient  importance  to  demand  special  attention  to  this 
feature  in  locating  hospitals. 

ACCESSIBILITY. 

It  is  of  the  greatest  importance  to  the  patients  occupying  beds 
in  hospitals,  as  well  as  to  their  friends,  that  the  institution  be  lo- 
cated at  a  point  which  can  easily  be  reached  by  them.  This  will 
also  make  it  possible  for  the  patients  who  are  very  ill  to  be  trans- 
ferred to  the  institution  without  great  danger  of  injury  from  the 
transportation  itself.  The  same  condition  will  secure  for  the  hos- 
pital upon  its  medical  and  surgical  staff  men  of  the  highest  skill 
and  ability,  who  could  not  spare  the  time  to  travel  a  considerable 
distance  into  tin  country  to  care  for  hospital  patients.  Since  the 
general  introduction  of  the  rapid  transit  facilities  and  the  automo- 
bile this  argument  has  lost  much  in  importance,  and  it  is  possible 
that  the  idea  long  favored  by  that  great  authority  on  hospital  mat- 
ters, Sir  Henry  C.  Burdett,  of  locating  all  hospitals  in  the  country, 
may  yet  be  realized. 


LOCATION    OF    EtOSPITAI,S 


117 


In  the  larger  cities  of  this  country  one  invariably  finds  manj 
limitations.  Were  it  possible  to  place  hospitals  in  the  middle  of 
our  public  parks,  it  would  be  an  easy  matter  to  secure  all  of  the 
conditions  which  have  just  been  mentioned.  It  is.  however,  rarely 
possible  to  obtain  more  than  a  city  Mock,  containing  five  acres  of 
land,  even  for  a  large  hospital.  A  careful  studj  of  conditions  in 
the  larger  cities  of  this  country  will,  however,  show  Hint  in  all  <>f 
the  details  mentioned  it  will  he  possible  to  secure  fair  conditions 
by  erecting  many  storied  buildings  in  .place  of  following  the  cot- 
tage system  which  was  so  popular  during  the  hitler  pari  of  the  last 


FIG.   •>. 

century.     It  will  he  interesting  to  consider  all  of  these  conditions 
from  the  standpoint  of  the  erection  of  high  buildings. 

Jn  considering  the  relative  merits  of  the  many  storied  hospi 
tals  as  compared  with   the  cottage   hospital,  a    number  of   points 
have  been  introduced  which  have  no  direct  relation  to  location,  but 
for  convenience  sake  it  has  seemed  proper  to  introduce  these  ele- 
ments at  this  point. 

LIG  III. 

In  order  to  illustrate  the  possibilities,  especially  for  securing 
favorable  conditions  for  lighting  and  ventilation,  a  diagram  has 
been  made  of  a  block  of  land  such  as  might  be  secured  under  the 
most  favorable  circumstances  bya  city  requiringa  hospital  for  500 


L18 


LOCATION    01'    EOSPITALfc 


patients.  This  Mock  contains  a  tract  of  five  acre-.  Figure  3 
represents  this  tract  of  land  containing  in  its  central  portion  an 
oblong  space,  representing  the  number  of  square  feet  required  for 
the  foundation  of  a  ten-storied  building,  which  would  readilyhouse 
500  patients,  al  the  same  time  furnishing  the  accessary  space  for 
the  administration  department  in  the  first  story,  and  the  operating 
department,  with  recovery  rooms  and  the  kitchen  department,  in 
the  top  story,  and  upon  each 'floor  a  sufficient  amount  of  space  for 
service-rooms,  diet-kitchen/  bathrooms,  toilet-rooms,  linen-rooms, 
etc. 

It  also  contains  a  second  space  to  be  occupied  by  the  boiler- 
house  and  laundry. 

Figure  4  represents  the  same  area  of  land  occupied  by  ten 


pig.  4. 

single-storied  pavilions,  also  calculated  to  bouse  500  patient-, 
with  the  accessary  operating-rooms,  kitchen,  boiler-rooms,  etc., 
giving  each  patient  the  same  amounl  <>!'  air  space  that  was  alloted 
in  Figure  '.'•. 

Figure  •">  corresponds  to  Figure  '■'<.  except  that  instead  of  a  five- 
acre  lot,  a  block  of  land  is  taken  such  as  is  common  in  most  of  the 
•  •ities  of  this  country,  having  a  frontage  of  520  feet  on  each  side. 

Figure  6  corresponds  t<>  Figure  4,  with  the  same  exception. 

A  glance  at  these  diagrams  will  demonstrate  a  number  of  im- 


LOCA.TIOS    oi-     BOSPITALS 


119 


portant  facts  which  arc  well  borne  out  m  practice  in  all  <>t'  the 
larger  institutions  which  have  been  built  in  the  Larger  cities  of  this 
country. 

In  Figures  3  and  5,  in  both  of  which  the  building  is  shown 
extending  from  north  to  south,  there  can  be  absolutely  no  obstruc 
tion  to  light.  The  dimensions  of  this  building  are  60x250  feet, 
with  the  hall  extending  the  entire  distance  from  north  to  south. 
This  condition  insures  for  every  room  and  every  ward  in  the  entire 
building  unobstructed  sunlight  during  seme  portion  of  the  day; 
one-half  being  exposed  to  the  morning  sun.  the  other  half  to  the 
afternoon  sun,  and  the  hall  to  the  noonday  sun.  The  building 
should,  of  course,  have  broad   verandas  at    the   north   and   south 


FIG.    •». 

ends,  with  broad  doors  communicating  with  the  central  hall,  per- 
mitting patients  to  he  placed  out  ol  doors  in  beds  or  on  couches  or 
in  wheel-chairs. 

The  same  conditions  apply  to  ventilation.  We  have  here  a 
building  which  is  absolutely  unobstructed  from  all  sides.  In  mosl 
cities  in  this  country  the  ventilation  must  come  during  the  greater 
portion  of  the  year  through  open  doors  and  windows,  and  there 
can  be  no  doubt  but  that  the  passage  of  ail  through  a  building 
standing  as  free  from  all  obst  ructions  as  t he  one  in  Figures  •">  and  5 
must  be  much  more  perfect  than  through  a  building  such  as  indi- 
cated by  Figures  4  ami  6. 


120 


LOCATION    OF    HOSPITALS 


It  is  a  well-known  fact  that  there  is  a  marked  difference  in  the 
rapidity  with  which  the  atmospheric  air  travels  near  the  ground 
and  at  a  considerable  elevation,  especially  if  there  are  large  ob- 
jects which  obstruct  the  circulation  near  the  ground;  consequently 
one  can  notice  a  difference  in  the  air  in  the  first  and  fifth  or  sixth 
stories  of  any  tall  building. 

In  considering  the  fact  of  ventilation  it  is  further  important 
to  bear  in  mind  the  advantage  that  can  be  obtained  by  getting 
awa\  from  the  dampness  of  the  earth.  No  one  would  choose  to 
sleep  in  the  first  story  of  his  dwelling  house,  because  the  air  in  the 


FIG.   G. 

second  or  third  story  is  practically  always  freer  from  ciampness. 
The  matter  of  dampness  is  -till  further  increased  if  a  considerable 
portion  of  land  is  covered  with  buildings,  because  of  the  shadows 
which  will  be  thrown  over  the  greater  portion  of  the  land  during 
the  various  parts  of  the  day. 

A  glance  at  Figures  3,  4.  .")  and  (i  will  convince  any  one  of  the 
vast  advantage  regarding  sunlight  and  natural  ventilation  which 
is  offered  by  the  many-storied  building. 

But  there  is  still  another  primary  consideration,  which  in 
large  cities  especially  is  of  great  importance,  the  contamination 
from  street  dust. 

Woodbridge   makes  the  following  statement:     "City  air,  as 


LOCATION    OF    1I<»IMTaI.S 


121 


h 


a 


d 


a 


f 


I 


b 


n 


j- -x. 


I 


t> 


S 


a 


d 


Fit!.  7. 


a,  ward  buildings;  b,  administration;  c,  physicians'  rooms;  d,  policlinic;  e,  dis- 
pensary; f,  kitchen;  g,  laundry;  h,  Sisters'  quarters;  i.  lockers  and  stable  building;  k, 

morgue;    I,  baths.     See  Fig.  294  also. 


122 


LOCATION    OK    HOSPITALS 


shown  by  reports  from  tests,  has  been  found  to  contain  as  many 
as  450,000  germs  to  the  cubic  foot.  The  dust  gathered  from  collect- 
ing places  within  rooms  of  buildings,  has  furnished  2,000  colonies 


FIG.  8. 


to  the  milligram  of  dust.  The  street  dust  in  the  cities  having  ma- 
cadamized roads  has  been  found  to  contain  from  30  per  cent,  to  50 
per  cent,  of  horse  droppings,  and  dust  from  hospitals  has  been 
found  to  contain  from  35  per  cent,  to  45  per  cent,  of  animal  matter. 
It  has  been  found  that  in  the  country  air  contains  far  less  dust, 
especially  of  organic  character,  than  in  the  city." 


LOCATION    OF    HOSPITALS  123 

Figures  4  and  6  show  thai  more  thai:  half  of  the  buildings  in 
the  cottage  plan  are  so  near  the  streel  thai  the  air  must  constantly 
be  filled  with  street  dust;  moreover,  experiments,  as  stated,  have 
proved  that  at  a  given  point  within  a  great  city  the  amount  of 
street  dust  at  the  level  el'  the  firsl  story  is  vastly  greater  than  the 
amount  in  the  higher  stories,  because  of  the  weight  of  this  dust. 

Aside  from  this  it  is  possible  to  place  a  natural  screen  betwe  in 
the  building  (iu  Figures  :;  and  5),  and  the  street,  in  the  form  of 
shrubbery  and  small  trees,  which  will  he  far  enough  away 
from  the  building  not  to  cause  dampness  of  the  soil  by  a  greal 
amount  of  shadow.  In  this  manner  the  greater  portion  of  the 
street  dust  can  actually  he  screened  out  of  the  air  before  it  reaches 
even  the  first  story  of  the  building— which,  of  course,  is  not  pos- 
sible if  the  building  is  placed  near  the  street,  as  it  musl  be  in  Fig- 
ures 4  and  6. 

What  has  been  said  can  he  illustrated  in  practice  by  a  study 
of  the  plots  of  some  well-known  hospitals.  Fig.  7  represents  the 
ground  plan  of  the  famous  hospital  Lariboisiere,  in  which  the 
amount  of  space  occupied  by  buildings  is  so  great  that  the  inter- 
vening space  is  covered  by  shadows  a  greal  portion  of  the  time. 
Fig.  8  represents  the  plan  of  the  equally  famous  hospital  Neues 
Allgemeines  Krankenhaus  zn  Hamburg-Eppendorf,  which  will  be 
mentioned  repeatedly  in  connection  with  this  work.  Figure  8 
also  shows  a  very  large  portion  of  the  ground  covered  with  build- 
ings; in  this  instance  the  danger  of  contamination  from  streel  dusl 
is  eliminated  by  the  planting  of  shrubbery  along  the  streel  in  fronl 
of  the  buildings. 


CHAPTER  X. 

ORIENTATION    OF    HOSPITAL    BUILDINGS    IN 
RELATION  TO  SUNLIGHT. 

The  subject  of  hospital  orientation  has  of  late  been  thorough- 
ly considered,  and  it  is  of  the  very  greatest  importance  in  the  plan- 
ning of  such  buildings.  In  a  recent  address,  Mr.  William  Atkinson 
has  considered  the  subject  so  carefully  in  connection  with  the  ori- 
entation of  streets  that  the  portion  relating  to  buildings  in  general 
can  be  applied  directly  to  the  planning  of  hospitals.  The  author 
has  kindly  consented  to  the  use  of  his  article  in  this  volume,  and 
the  following  pages  are  quoted  verbatim: 

"The  Orientation  of  Buildings  and  of  Streets  in  Relation  to 
Sunlight"  is  a  subject  that  I  have  been  led  to  investigate  in  con- 
nection with  the  study  of  hospital  architecture,  but  the  results  are 
equally  applicable  to  the  construction  of  all  buildings  occupied  for 
residential  purposes.  If  sunlight  is  essential  for  the  recovery  of 
the  sick,  is  it  not  a  still  more  powerful  agent  in  the  prevention  of 
disease .' 

''Unquestionably  the  first  requisite  for  a  hospital  is  abund- 
ance of  sunlight.  Not  only  the  exterior  wall  surfaces  of  the  build- 
ings, but  also  the  ground  surfaces  between  and  around  them  shouid 
have  the  direct  rays  of  the  sun  for  as  long  i  time  as  possible  each 
day. 

"Second  only  to  air  is  liglit  and  sunshine  essential  for  growth 
and  health;  and  it  is  one  of  Nature's  mosi  powerful  assistants  in 
enabling  the  body  to  throw  oft'  those  conditions  which  we  call  dis- 
ease. Not  only  daylight,  but  sunlight;  indeed,  fresh,  air  must  be 
sun-warmed,  sun-penetrated  air.  rl  he  sunshine  of  a  December  day 
has  been  recently  shown  to  kill  the  spores  of  the  anthrax  bacillus.  " 
(Galton,  "Healthy  Hospitals  ") 

"Wail  surfaces,  especially  brick  walls,  absorb  a  large  amount 
of  moisture  during  rains.  This  moisture  is  quickly  dried  out  by 
exposure  to  sunlight,  but  is  retained  for  a  long  time  in  walls  which 
are  not  exposed  to  the  sun,  and  creates  an  unhealthy  condition;  for 
dampness,  with  lack  of  sunlight,  is  a  combination  favorable  to  the 
growth  of  low  forms  of  vegtable  life,  and  should  be  avoided  in  hos- 


ORIENTATION   OF    HOSPITALS   IN    RELATION    TO  SUNLIGH 


1 25 


pital  buildings.  To  secure  sunlight  in  the  fullest  measure  requires 
that  the  genera!  plan  of  the  buildings  shall  be  carefully  studied 
with  this  end  in  view. 

"In  the  study  of  existing  hospitals  I  have  found  the  greatest 
divergence  in  the  orientation  of  the  buildings.     It  therefore  seemed 


W^ 


Q 


•L 


FIG.  9. 


to  me  advisable  to  make  an  investigation  of  the  subject,  and  sev 
oral  years  ago  T  obtained  from  the  Harvard  Observatory  a  table 
showing  the  position  of  the  sun  for  differenl  periods  of  the  year, 
and  the  data  thus  obtained  are  embodied  in  a  sun  chart  which  T 
will  now  show  you.     I  Pig.   15. ) 


126  ORIENTATION   OF   HOSPITALS  IN   RELATION   TO  SUNL1GH1 

"Astronomy  is  not  studied  nowadays  as  it  used  to  be,  and 
perhaps  it  will  be  well  to  refresh  our  -astronomical  knowledge  a 
little.  These  three  diagrams  show  the  position  of  the  sun  at  each 
hour  of  the  day  for  the  three  typical  seasons  of  the  year:  Decem- 
ber 21.  the  shortest  day.  March  21  and  September  21,  the  e<iui- 
noxe>.  and  the  Longesi  day,  dune  21.  There  are  several  things  that 
it  will  be  convenient  to  fix  in  our  minds.  In  t lie  first  place,  we  see 
that  the  sun  rises  pretty  nearly  in  the  northeast  in  summer  and 
sets  pretty  nearly  in  the  northwest,  and  in  winter  the  same  dis- 
tance southeasl  and  southwest.  At  the  time  of  the  equinoxes  it 
rises  in  the  east  and  sets  in  the  west. 

••Another  thing-  convenient  to  remember  is  that  in  dune  about 
8  o'clock  in  the  morning-  the  sun  is  very  nearly  due  east,  and  at  4 
o'clock  in  the  afternoon  very  nearly  due  west.  Then  I  would  like 
you  to  observe  the  low  altitude  of  the  sun  at  noon  in  winter  and 
the  high  altitude  in  summer.  In  one  sense  the  period  of  equinoxes 
may  represent  the  average  day  because  it  is  intermediate 
between  the  two  extremes;  but  the  declination  of  the  sun  i^  chang- 
ing much  more  rapidly  at  those  periods  than  it  is  in  June  and  De- 
cember. Consequently  there  are  a  great  many  more  days  which 
resemble  the  21st  of  December  in  winter  and  a  great  many  more 
days  in  summer  which  are  typified  by  June  21st  than  there  are 
days  which  are  typified  by  March  21st  and  September  21st.  You 
will  find  if  you  consult  the  almanac,  that  the  length  of  days  is 
changing  very  slowly  around  December  21st,  and  June  21st,  and 
very  rapidly  at  the  time  of  the  equinoxes.  For  instance,  two  weeks 
before  December  21st,  the  length  of  the  day  is  only  eight  minutes 
longer  than  on  December  21st.  So  about  June  21st,  two  weeks  be- 
fore and  after,  the  day  is  only  a  few  minutes  (about  seven  or  eight) 
shorter  than  ii  is  on  June  21st.  On  the  other  hand  two  weeks  be- 
fore March  21st,  and  two  weeks  later,  on  April  4th.  it  is  forty  min- 
utes longer. 

"The  time  shown  upon  these  diagrams  is  the  time  as  shown  by 
a  sundial,  which  is  different  from  our  eastern  time,  but  the  correc- 
tion in  each  case  can  be  made  by  consulting  the  almanac. 

"This  slide  represents  what  1  call  the  "firsl  lesson"  in  orien- 
tation. It  represents  a  building  square  in  plan.  In  one  position  it 
is  set  squarely  with  the  meridian,  and  in  the  other  the  meridian 
passes  through  the  diagonal.  Yen  can  see  thai  in  the  first  the 
north  wall  will  obtain  no  sunlighl  at  all  during  half  of  the  year, 
whereas  in  the  second  all  four  walls  of  the  building  will  have  more 
or  less  sunlighl  at  all  >e,-isons  of  the  year.  The  typical  home  of  the 
Swis>  mountain  dweller  is  a  square  building  sel  on  the  diagonal 
with  respeci  to  the  meridian,  and  the  living  room  i>  placed  at  the 


ORIENTATION    OF    HOSPITALS    IN    RELATION     I"  SUNLIGHT 


\S 


southern  apex.    Evidently  the  dwellers  in  these  mountains  learned 
to  appreciate  the  value  of  sunlight  at  a  very  early  date. 

"This  diagram  (Fig.  9)  represents  the  shadow  plan  of  a  cube 
placed  in  the  two  positions  I  have  shown.  The  shadows  are  drawn 
for  each  hour  of  the  day  and  are  superposed  one  upon  the  other, 


e 


fii  .  LO. 

and  the  degree  of  blackness  corresponds  roughly  Lo  the  length  of 
time  in  which  thai  particular  spol  is  in  the  shadow  during  the  di 
the  full  black  in  thai  case  represents  an  area  which  is  in  sunlight 
for  less  than  one  hour.  Yon  will  observe  that  in  this  position  (A)  of 
the  cube  there  is  a  very  considerable  triangular  area  here,  mucn 
larger  than  in  the  one  (B),  which  has  very  little  sunlight,    [n  other 


128 


ORIENTATION   OF    HOSPITALS  IX  RELATION  TO  SUNLIGHT 


woids,  a  square  building  placed  in  the  latter  position  shades  the 
ground  around  it  very  much  less  than  a  similar  building  placed  in 
thai   position   (A).     The  diagram  suggests    another    and     better 


FIG.   11. 

method  of  representing  these  matters  by  means  of  curves.  The  in- 
tersection of  the  various  shadows  will  determine  one  series  of 
points  in  shadow  for  two  hours,  and  so  on;  and  by  joining  these 


ORIENTATION    OF    HOSPITALS    !N    RELATION   TO  SUNLIGH1 


L2! 


points  we  obtain  a  series  of  curves  which  maj    be  called  sliadow 
curves  of  the  cube. 

"The  next  diagram  (Fig.  LO)  will  show  these  shadow  curves 
for  March  21st  and  September  21st.  h  each  area  the  numerals 
indicate  the  number  of  hours  during  which  thai  area  is  without 
sunlight,  Similarly  we  might  draw  such  a  shadow  diagram  for  .1 
building  of  any  shape  by  pursuing  the  same  method,  but  practical- 
ly we  find  that  almost  all  buildings,  especially  hospitals,  are  com- 


N 

Duration  -ob  om 

. 

1—1 

r-i 

- 

N 

Duration     : 

600AM-  840  AM 

L 

Quantity     17  3j  f  h 

00 

" 

y 

A 

.Duration    £h  is  m 

K 

} 

600AM-  Ills  AM 

p 

Quantity  81 0  Fh 

/ 

7SO 

108 

2*OD 

2So8 

1 

14  oc 

1 — 1 

, 

;> 

E 

c 

A 

Duration   7h»m 

600AM-IJOPM 

J 

V 

Quantity  io4  68  f  h 

4~7s 

1725 

I960 

2000 

1870 

- 

714 

2  6C 

v 

Is 

N. 

[^ 

„ 1 

y\ 

A 

,s 

|            1 

r 

*  b  O  ro 

730AM- 

-, 

-J 

1 1 

u 

/ 

. 

189 

696         |          IOGO 

1944 

'         ' 

K>60 

■  » 

• 

r___1 

| 

[— 1 

s 

Duration     yh  30m 

h 

s 

l> 

1030AM—  6  00PM 

vv 

<i*anbly    I046S  fh 

II 

s 

I 

260 

1 

- 

It  JO 

■ 

I960 

M45 

Duration 

SI.  15m 

h 

\ 

*a« 

vv 

11 43PM- 

-600PM 

§ 

Quantity 

Bigsfh 

\ 

k 

vo» 

7Bo 

■4  06 

'. 

w 

Duial'OQ   a>i4ooi 

3  x>PM-6ooPM 

Quantity.  17  37  fk 

3JO 

*.v 

TT 

1        1       1        B        I        XI 

Ml           1           II           111          1111          V           yi 

FIG.    12. 

posed  in  their  elements  of  two  wings  forming  an  L,  or  three  wings 
forming  a  U-court.  Especially  are  hospitals  composed  of  LT-conrts, 
so  that  if  we  study  the  U-courl  we  have  accomplished  the  greater 
part  of  the  necessary  study. 

'" If  we  study  the  shadow  plan  of  such-  a  U-couri  (Fig.  1.1).  we 
shall  find  the  raosi  advantageous  position  is  thai  in  which  the  court 
Paces  southeasl  or  southwest,  and  tin  leasl  advantageous  is  thai  in 
which  the  courl  faces  the  north;  and  yel  how  often  do  we  sec  build- 
ings constructed  on  this  plan  with  the  courl  facing  the  north 


130 


ORIENTATION  OF   HOSPITALS  IN   BELATION   TO  SUNLIGHT 


"So  far  we  liave  considered  the  outside  surfaces  of  the  build- 
ing and  the  surface  of  the  ground  around  it.  We  now  proceed  to 
study  the  interior  lighting  of  the  buildings.  This  diagram  (Fig. 
12)    illustrates  the  subject   of  windows.     These  various   patches  of 


l>i-c  ernbei  21 


■I  larch  ii  Septembcr-ai- 


1  (eccmbep  -1 


1  Ian  I.  -i    September- 2 2 


1  '.<  ember  si- 


ISO 

:  '  leptember  22 


■Deceinber-2i 


•t-SO\  /    7'50 

1  larch  -i   September-22 


FIG.    13. 

different  shapes  represenl  the  cross  sections  oi  a  prism  of  lighi 
rays  passing  through  -i  window  s  feel  high,  '■>'■■_  feet  wide  and  a 
thickness  of  1  fool  in  the  wall.    Now  by  multiplying  the  area  of  anj 


ORIENTATION    OF    HOSPITALS   IN    RELATION     l<     SUNLIOH1 


one  of  these  figures  by  the  length  of  time  during  which  the  sun  is 
shining  through  the  aperture  of  thai  shape,  we  shal]  obtain  what  1 
call  'quantity'  of  sunlighl  expressed  in  'sun-hours,'  the  sun-hour 
being  the  amount  of  sunlighl  received  i>\  a  surface  1  fool  square 
exposed  to  the  sun  for  one  hour. 

••This  diagram   (Fig.   L3)   illustrates  the  illumination  of  the 
floor  through  the  window,  and  if  the  floor  of  thai  room  wei<-  cov 


ii...  14. 

ered  with  a  carp<  I  dyed  in  aniline  colors,  we  should  find  al  the  cud 
ol*  the  day  the  unshaded  portion  somewhal  faded,  because  thai  rep- 
resents the  area  of  the  floor  which  has  received  sunlighl  during 
the  day.  The  diagram  is  drawn  for  the  four  typical  seasons  of  the 
year.  The  south  window  is  one  of  the  extremes ;  in  winter  ii  tran 
niits  a  great  amount  of  sunlight,  hut  in  summer,  owing  to  the  great 
altitude  of  the  sun.  this  small  patch  of  floor  is  all  thai  receives  sua 


132  ORIENTATION   OF   HOSPITALS  IX    RELATION    TO  SUNLIGHT 


lighl  during  tin  day;  so  the  south  window  is  a  very  coo!  one  in 
summer  and  ;  very  warm  one  in  winter.  I'>\  superposing  these 
areas  on  any  given  plan  we  can  obtain  the  Horn-  illumination  of  a 
room  of  any  shape  and  with  windows  variously  placed. 

For  instance,  this  diagram  (Fig.  14)  represents  an  open  ward 
in  a  hospital." 

This  work  of  Mi'.  Atkinson's  thoroughly  establishes  a  scien- 
tific basis  for  the  placing  of  hospital  buildings  as  regards  the  in- 


■      u 


troduction  of  sunlight.  Mr.  A.tkinson  has  also  made  a  most  careful 
study  of  the  distribution  and  depth  of  shadows  in  connection  with 
buildings  of  various  forms.  The  principal  forms  being  those  con- 
sidered in  tic  classification  of  hospital  plans  by  Sir  Henry  0. 
Burdett. 


(.i;ii::;i'a:'io\  of  hospitals  i x  relation  to  sunlight  133 

1 — The  single  straight  Mock. 
- — Two  blocks  arranged  as  an  ell. 
3 — Three  blocks  arranged  as  the  letter  U. 
4— Three  blocks  arranged  as  the  letter  H.      . 
These  i'onns   have   been  placed   in    various   positions   so   thai 
each  wall  in  turn  extends  from  north  to  south,  from  easl  to  west, 

Key  to  Figures  16,  17,  18,  ig. 
Without  sunlight  from  8  a,  m.  to  4  p.  m. 

Without  sunlight   from  8  a.  m.  to  6  p.  m.  or   from  (1  a.  m.  to 

4  p.  111. 

Withoul   any   sunlight   whatever   during   the  entire  day. 

from  northeast  to  southwest,  from  northwest  to  southeast.  The 
shadows  are  represented  at  various  depths  and  indicate  the  per- 
centage of  wall  surface  which  was  without  sun  at  any  time  during 
the  day,  between  the  hours  of  8  a.  m.  and  4  p.  m. 

Fig.  16  represents  a  single  oblong  building  placed  from  north 
to  south.  At  A  it  will  be  seen  that  the  area  of  ground  which  re- 
ceives no  sunlight  between  the  hours  of  8  a.  ni.  and  4  p.  m.  is  ex- 
ceedingly small.  If  this  building  is  constructed  on  the  general 
plan  which  was  represented  in  Fig.  1.  then  the  windows  on  the  en- 
tire east  side  of  the  building  will  receive  sunlight  during  the  entire 
morning;  the  sun  will  actually  enter  the  room  until  a  little  after  1 1 
o'clock.  All  of  the  windows  on  the  west  side  of  the  building  will 
receive  sunlight  during  the  entire  afternoon;  the  sun's  rays  will 
enter  the  rooms  from  about  1  o'clock  on.  The  hall  will  be  exposed 
to  sunlight  from  8  o'clock  in  the  morning  until  4  o'clock  in  the 
afternoon,  receiving  almost  parallel  rays  during  the  noon  hour. 

Again,  referring  to  what  has  just  been  said  concerning  the 
difference  between  summer  and  winter  sun,  it  will  be  seen  that  the 
hall  will  be  more  thoroughly  sunned  during  the  winter  months, 
when  sunlight  is  most  desirable. 

Referring  to  B,  Fig.  1<>,  it  is  plain  thai  if  Hie  same  general 
plan  is  employed  that  is  shown  in  fig.  1.  aside  from  room  S  and 
room  1,  the  entire  north  side  of  the  hospital  will  contain  rooms 
which  receive  no  sunlight  at  any  time  during  the  day.  Booms  1<> 
to  14  inclusive  will  receive  sunlight  from  8  a.  m.  to  -I  p.  m.  Room 
1.")  will  receive  sunlighl  from  sunrise  until  1 1  a.  m.,  ami  room  8  will 
receive  sunlight  from  1  p.  iii.  until  sunset. 

It  is  plain  thai  this  plan  of  placing  a  pavilion  would  be  mosl 
unsanitary. 

Were  the  general  plan  represented  in  Wig.  2  adopted  with  a 
hall  extending  along  the  north  wall  of  the  building,  (he  sanitary 


1£4 


ORIENTATION    OF    HOSFITALS   IN    RELATION    TO  SUNLIGH" 


conditions  as  regards  the  use  of  sunlight  would  be  very  satisfac- 
tory. 

In  C,  Fig.  16,  the  pavilion  extends  from  southwest  to  north- 
east; in  both  of  those  structures  there  is  no  portion  of  the  sur- 
rounding ground  which  is  not  exposed  to  the  sunlight  during'  some 


portion  of  the  time  between  8  a.  m.  and  4  p.  in.  This  ensures  the 
sunning  of  the  entire  hospital  grounds  and  ail  of  the  outside  walls. 
Every  window  in  the  hospital  receives  sunlight  during  a  portion  of 
the  day.  There  is,  however,  this  important  fact  to  he  borne  in 
mind,  that  although  the  windows  themselves  are  exposed  to  sun- 


ORIENTATION   OF    HOSPITALS    IX    RELATION     CO  SUNLIG] 


13 


light,  the  portion  of  the  walls  L-g  and  f-g,  in  C  and  D,  Fig.  16,  pre- 
vents the  actual  entrance  of  any  considerable  amount  of  sunlight 
into  the  rooms  during  the  winter  months  when  sunlight  is  most  ap- 
preciated. This  is  so  because  in  winter  the  sun  rises  in  the  south- 
east, and  sets  in  the  southwest,  as  shown  in  A.  Pig.  L5. 


During  the  summer  months,  when  the  sun  rises  in  the  north 

east  and  sets  in  the  northwest,  as  shown  in  C,  Fig.  L5,  this  condi- 
tion is  changed  because  in  these  walls  the  windows  will  admit  a 
considerable  amount  of  sunlighl  until  about  !»  o'clock  in  the  morn- 
ing.   The  walls  i  e  ami  e-l  are  placed  very  favorably  tor  the  pec 


136  ORIENTATION   OF    HOSPITALS   IX   RELATION  TO  SUNLIGHT 

tion  of  sunlight  both  in  summer  and  winter.  Were  it  feasible  from 
the  standpoint  of  economy  to  employ  the  general  plan  represented 
in  Fig.  2,  most  favorable  conditions  could  be  obtained  by  placing 
the  long  halls  along  the  walls  J',  g,  C,  Fig.  Ki,  and  g,  !.  1 ),  Fig.  16, 
thus  exposing  the  side  of  the  hospital  containing  the  rooms  along 
the  wall  e-]  in  C,  Fig.  L6,  and  f-e  in  I),  Fig.  Ki. 

In  considering  the  plan  of  two  wings  of  a  hospital  in  the  form 
of  the  letter  L.  as  shown  in  Pig.  17.  we  have  a  combination  of  the 
shadows  represented  in  A  and  B,  Fig.  16,  together  with  the  condi- 
tion represented  in  II,  Fig.  17,  in  which  a  considerable  portion  of 
the  ground  receives  absolutely  no  sunlight  between  the  hours  of  8 
a.  in.  and  4  p.  in. 

What  has  been  said  regarding  A  and  B,  Fig.  16,  is  true  of  A,  G, 
E,  (I,  Fig.  17;  and  what  has  been  said  of  the  effect  of  sunlight  in  C, 
I),  Fig.  16,  is  also  true  of  B,  D,  F,  H,  in  Fig.  17:  the  unfavorable 
conditions,  however,  being  badly  exaggerated  in  H,  Fig.  17,  be- 
cause the  advantage  which  each  wing  obtains  from  its  oblique  posi- 
tion is  Lost  by  the  fact  that  a  considerable  portion  of  the  walls  on 
the  northeast  side  of  the  west  wing,  and  northwest  side  of  the  east 
wing  are  constantly  in  each  other's  shadow. 

The  least  unfavorable  of  these  structures,  so  far  as  sunlight  is 
concerned,  is  found  in  I),  Fig.  17,  provided  the  building  is  con- 
structed so  thai  the  hall  extends  along  the  wall  f,  g,  1,  and  the 
rooms  along  the  opposite  wall. 

Another  plan  will  be  shown  later  according  to  which  this  form 
of  a  hospital  placed  as  shown  in  I),  Fig.  17,  may  be  made  satisfac- 
tory as  regards  the  use  of  sunlight.  This  implies  the  use  of  large 
wards  in  public  institutions  in  which  a  long  wing  is  utilized  as  an 
open  ward,  the  east  wing  receiving  an  abundance  of  sunlight 
through  the  walls,  1-h  and  h-i,  the  west  wing  receiving  an  equal 
amount  through  the  windows  in  walls  f-e  and  e-i. 

The  same  principle  may  be  applied  to  buildings  constructed 
according  to  15  and  F.  Fig.  17.  A.  C,  E  and  G  maj  be  utilized  in  a 
fairly  satisfactory  manner  by  placing  the  elevator  and  stairs,  the 
diet  kitchens  and  serving  rooms  on  the  side  of  the  building  con- 
taining the  shadows,  and  utilizing  the  other  portions  for  wards  and 
rooms.  Of  these  figures  A  and  <l  are  the  most  favorable,  because 
in  these  part>  of  the  building  the  portion  of  wall  which  is  entirely 
unexposed  to  the  sun's  rays  between  the  hours  of  8  a  in.  and  1 
p.  in.,  is  comparatively  small. 

In  A.  Pig.  17.  the  shadow  upon  the  wall  b-c  may  practically  be 
ignored  because  an  abundance  of  light  for  that  portion  of  the  build- 
ing can  be  obtained  through  the  windows  in  walls  a  h  and  c  d.  The 
shadow  d  c  i  may  lie  ignored  in  par'  as  the  windows  in  wall'e  f  will 


ORIENTATION   OF   HOSPITALS   IN    RELATION     CO  SUNLIGHT 


137 


supply  sunlight  for  a  portion  of  the  end  of  the  building  affected  by 
this  shadow. 

(i.  Fig.  17,  is  exactly  the  reverse  of  A,   B'ig.   17.  and  conse- 
quently the  same  criticism  would  apply  to  this  form  of  building, 

In  both  of  these  rooms,  elevator,  diet-kitchen  and  stairs  should  1m- 


t 


■:•:■>" 

placed  along  the  portion  of  the  walls  indicated  by  the  lines  e  i  and 
d  i,  the  remaining  wall  space  being  utilized  for  room-  and  wards. 

The  most  popular  of  all  forms  of  construction,  in  large  cities 
at  least,  is  that  represented  by  three  wings  placed  in  the  form  of 
the  letter  U,  as  shown  in  Fig.  18.     A  combination  of  the  conditions 


;.">s  ORIENTATION    OF    HOSPITALS   IX    RELATION     CO  SUNLIGHrJ 

represented  in  Figs.  h'»  and  17  will  produce  the  conditions  repre- 
sented in  Pig.  Is.  A  study  of  the  separate  figures  in  this  illustra- 
tion will  at  once  condemn  Three  of  the  positions  indicated,  namely 
A.  B  and  11.  and  of  these  A  is  undoubtedly  the  most  undesirable, 
as  it  contains  the  greatesl  area  of  ground,  and  the  greatest  area  of 
wall  space  which  receives  absolutely  no  sunlight  between  the  hours 
of  s  a.  in.  and  4  p.  m.  The  same  objections  that  were  urged  against 
the  walls  f  g  in  ( '.  Pig.  L6,  and  u'  1  in  D,  Fig.  16,  will  apply  to  the 
walls  f  g  and  g  lin  1)  and  F.  Pig.  1*.  and  to  f  g  in  B  and  g  I  in  H, 
Pig.  IS.  One  of  the  most  satisfactory  positions  for  a  hospital  of 
this  form  is  shown  in  E,  Fig.  IS,  t],js  is  also  shown  in  its  practical 
application  in  hospital  construction  in  Fig.  320,  and  this  will  be 
discussed  in  all  its  details  later. 

The  form  and  position  as  shown  in  F,  Fig.  18,  is  worthy  of  our 
very  careful  consideration.  In  this  plan  the  halls  should  extend  as 
indicated  in  Fig.320,  with  large  windows  at  the  end  of  each  hall  and 
al>o  in  the  center  of  the  wall  d  e,  Fig.  18.  The  walls  a  b  and  e  f  will 
he  exposed  to  the  sunlight  the  entire  afternoon,  the  walls  e  d  and 
g  h  the  entire  forenoon.  The  walls  a  c  and  f  g  will  be  exposed  all 
day.  Portions  of  the  wall  d  e  will  also  he  exposed  to  the  sunlight 
during  the  entire  day;  this  will  leave  only  the  walls  b  h  without 
sunlight  between  the  hours  of  8  a.  m.  and  4  p.  in.  It  will,  however, 
he  possible  to  secure  sunlight  for  a  considerable  portion  of  this 
space  by  arranging  the  rooms  as  indicated  in  Fig.  .'!_'(),  because  the 
windows  placed  in  the  walls  a  b  and  g  h  will  readily  supply  this 
light.  The  remaining  portion  of  the  space  along  the  wail  b  h  can  be 
utilized  for  elevators,  stairway,  diet  kitchens  and  service  rooms, 
ami  in  general  hospitals  for  the  rooms  allotted  to  eye  patients,  as 
these  rooms  can  be  more  easily  darkened  than  they  could  be  were 
they  situated  in  the  sunny  portions  of  the  hospital. 

In  many  storied  buildings  the  top  story  can  be  utilized  for 
operating  rooms,  thus  securing  north  light,  which  is  the  best  possi- 
ble light  for  this  purpose.  By  still  further  combining  these  wings 
T  pavilions  a  form  will  be  obtained  which  may  be  represented  by 
the  letter  II,  as  shown  in  Fig.  1!/.  This  is  virtually  a  combination 
of  the  forms  A  and  F.  C  and  (I.  B  and  F,  1)  and  II.  Fig.  L8,  placed 
in  groups. 

What  has  been  said  in  the  discussion  of  forms  in  Pig.  IS  will 
apply  fully  to  the  forms  in  Pig.  1'.).  In  some  of  the  larger  munici- 
pal hospitals  in  which  the  male  and  female  patient.-  must  be  separ- 
ated, form  A.  Pig.  If),  presents  many  attractive  features  if  the  por- 
tion a  b  <•  d  in  A.  Pig.  1!),  is  built  up  not  more  than  two  stories  high 
in  the  many  storied  building,  this  portion  being  utilized  for  the 
administration  department,  and  the  two  wings  being  used  one  for 


ORIENTATION    OF    HOSPITALS    IN    RELAl'lOS    TO  SI    XI.ICHT 


139 


the  male  and  one  for  the  female  patients.  The  advantage  from  the 
point  of  convenience  of  the  central  location  for  the  department  of 
administration,  is,  however,  not  so  great  when  compared  to  the 
conditions  in  Fig.  320,  to  make  this  form  desirable.  The  space  oc- 
cupied by  the  elevator  and  stairs,  by  the  service  rooms  and  diet 
kitchen  may  be  placed  along  the  wail  b  <•  to  advantage 


Atkinson  has  shown  that  in  the  space  represented  by  Pigs.  L6. 
17,  18  and  1!),  the  following  percentage  of  wall  surface  is  without 
sun  at  any  time  during  the  day  between  the  hours  of  8  a.  in.  and 
4  p.  m.  In  Pig.  16,  A.  Il'i.,  per  cent;  B,  37U  per  cent;  C  and  D, 
none;  Fig.  17.  \.  28  per  cenl ;  !(>.  none;  < '.  25  per  ceni  ;  I '.  none;  E, 
25  per  cent;  F.  none;  (i.  28  per  cent ;  II.  lo  per  cent.     Pig  is.  a,  27 


140  ORIENTATION   OF    HOSPITALS   !  N    BELATION    !'< >  Sl'.\  LIGHT 

percent;  B,  7  per  cenl ;  ( '.  30  per  cent;  l>.  none;  E,  22  per  cent;  F, 
none;  G,  30  per  cent ;  1 1.  7  per  cent. 

It  is  plain  that  a  Large  number  of  variations  may  be  produced 
by  placing  these  buildings  at  every  possible  angle  and  by  combin- 
ing a  number  of  these  forms,  but  perhaps  this  discussion  will  be 
sumicent  to  at  least  demonstrate  the  necessity  of  giving  careful  at- 
tention to  this  element  in  the  construction  of  hospitals. 


CHAPTER  XI. 

MASONRY. 

Grade. — In  establishing  the  grade  of  building  to  be  erected, 
if  it  is  possible  to  do  so,  the  highest  point  should  be  taken  as  inside 
grade,  and  the  entire  lot  graded  off  from  this  point  with  a  slight 


FIG.  20. 

slope,  in  order  to  give  perfect  drainage  al  nil  times.  Where  this 
is  not  expedient,  owing  to  the  necessity  of  locating  the  hospital 
advantageously,  as  herein  mentioned,  it  is  well  to  ink'-  the  highest 
point  within   practical  limits,  and  grade  the  entire  lo1  to  such  a 


^42  >!  ^-SONPvi 


point.  The  primary  object  in  tins  should  be  to  afford,  as  stated, 
a  perfect  drainage  away  from  the  building,  and  to  properly  facili- 
tate the  keeping  of  the  basemenl  m  a  dry  and  sanitary  condition. 
Excavations.  Having  decided  ilhs  point,  the  matter  of  ex- 
cavations is  of  next  importance;  as  too  often  the  specifications  do 
not  call  for  this  in  a  proper  manner.    Care  should  he  taken  that  in 


FIG. 


21. 


making  the  excavations  they  be  sufficiently  larg<  to  admit  of  the 
working  on  the  walls  outside,  which  are  to  he  covered  only  after 
the  foundations  are  above  grade.  The  object  in  doing  this  is  to 
permil  plenty  of  room  for  the  damp-proofing,  so  that  this  may  he 
inspected  as  well  as  properly  done,  and  because  the  cementing  of 
damp  courses  between  the  footings  and  the  foundations  is  a  mat- 


MASONS*  143 

ter  which  requires  special  attention  and  musi  be  done  in  a  space 
where  easy  working  is  possible. 

Footings.- —The  matter  of  footings  must  be  Left  entirely  to 
the  architect,  but  as  far  as  practicable  these  should  be  of  concn 
and  put  in  so  that  the\  will  adequately  bear  the  building.  Too 
often  footings  are  designed  for  a  hospital  which  may  be  of  suffi- 
cient area,  but  proper  care  is  not  taken  in  making  them  in  such 
a  manner  that  damp-proofing  can  be  facilitated.  Damp  courses,  if 
used  instead  of  cement  coatings  which  have  been  damp-proofed 
by  the  process  described  below,  must  be  built  in  with  the  founda- 
tion walls,  laid  in  proper  cement  and  in  approved  manner,  so  that 
they  are  what  their  name  implies.  They  musi  have  sufficient  pro- 
jection beyond  the  outside  wall  (Fig.  20),  so  that  the  cementing  of 
these  walls  can  be  easily  done,  and  there  must  be  sufficient  pro- 
jection into  the  building  so  that  the  damp-proofing  of  the  floor 
and  that  of  the  walls  will  be  continuous  (Fig.  21). 

Foundations. — The  foundation  work  must  be  given  special 
attention.  It  will  not  suffice  to  build  foundation  walls  as  is  done  in 
buildings  of  ordinary  character.  It  is  probably  necessary  in  the 
hospital  more  than  in  any  other  building  known  that  these  should 
be  built  correctly,  and  too  much  care  cannot  be  given  to  this  part 
of  the  work.  Such  foundations  should  either  be  built  entirely  of 
concrete,  well  plastered  with  cement  which  lias  been  water-proofed 
with  the  compounds  mentioned,  or  if  built  of  stone  should  be  laid 
in  cement  mortar,  and  the  utmost  care  taken  to  damp  proof  these 
walls,  especially  on  the  outside,  so  that  none  of  the  soil  gases  or 
dampness  can  penetrate  them.  Care  must  be  exercised  so  thai 
none  of  the  so-called  damp-resisting  paints  or  damp-resisting 
methods  be  applied,  unless  they  have  been  thoroughly  tested  for 
their  permanent  elasticity  and  their  ability  to  withstand  gases  if 
those  with  felt  are  employed.  A  good  coat  of  cement,  with  damp- 
proofing  material  mixed  in  dry  before  it  i>  applied,  is  thoroughly 
good  and  has  the  added  advantage  of  economy.  The  compound 
is  a  powder  used  in  very  small  percentage  of  the  weighl  of  drj 
cement  and  will  make  the  latter  impervious  t«>  water. 

There  are  several  ways  of  building  foundation  walls,  and  a 
multitude  of  materials  from  which  thej  can  he  built,  all  of  which 
must  be  left  to  the  discretion  of  the  architect,  and.  to  some  extent, 
to  the  conditions  existing  for  obtaining  of  material  for  these  wall-. 

In   leaving  holes  in  the  foundations  for  drain-,  gas  and  \\;ii  a 
pipes,  the  utmost  care  must  be  exercised  t"  see  that  these  are  tighl 
ly  closed  after  the  pipes  are  in  place.     If  it  is  possible  to  do   $o, 
excavation  should  he  loft  open  until  all  work  of  this  character  is 


144 


MASONRY 


completed.  This  is  not  always  expedient,  nor  always  necessary, 
Imt  it  is  a  good  rule  to  follow  where  it  can  be  done. 

Extebiob  Material.— Id  selecting  material  for  the  superstruc- 
ture it  will  he  necessary  to  use  such  as  will  best  carry  out  the  de- 
sign of  the  building,  but  \uh]a>\-  no  circumstances  should  the  latter 
be  made  the  primary  purpose  in  the  construction  of  the  building, 
rather  the  design  should  be  subservient  to  the  material  of  which 
it  is  best  to  build  the  hospital.  Jt  will  take  no  great  amount  of 
genius  to  use  whatever  materials  are  at  band  and  best  fitted  for 
the  work,  to  make  a  practical  as  well  as  an  artistic-looking  build- 
ing. 

The  watercourse  can   be  of  either  terra  eotta  or  stone  and 


ftg.  22. 

should  be  waterproofed  on  five  sides  with  damp-resisting  com- 
pounds to  keep  out  moisture.  Structure  above  that  point  must  be 
left  to  the  architect  to  carry  out  his  desion. 

It  lias  bee!)  found  that  the  material  best  suited  for  the  exterior 
of  hospitals  is  brick,  with  stone  or  terra  eotta  trimmings,  but  stone, 
terra  eotta  and  even  cement,  the  latter  in  either  reinforced  work 
or  in  blocks,  or  a  combination  of  all,  can  be  used.  Paving  brick 
can  be  used  with  a  greater  degree  of  economy  and  with  better  re- 
sults for  tight,  non-absorbent  walls  than  almost  any  other  material 
known.  These  should  be  laid  in  cement  mortar  and  not  more  than 
eight  feet  in  height  to  each  length  of  wall,  as  there  is  liable  to  be 
a  decided  slippage  if  there  is  too  much  weight.    But  of  whatever 


MASONRY 


145 


material  the  structure  be  built,  tin  primary  objecl  should  always 
be  to  carry  out  the  work  with  a  view  to  economy  withoul  making 
an  unsightly  building.  The  outside  walls,  i!  of  stone  or  Wrick, 
other  than  paving  brick,  can  be  treated  with  washes  made  for  this 
purpose  to  prevent  saltpeter  stains  and  to  waterprooi  the  material. 
The  inside  of  the  outside  walls  can  be  treated  in  several 
ways — namely:-  Furring  with  the  hollow  tile  (Fig.  22);  hollow 
brick  (Fig.  23);  concrete  blocks  (Fig.  24),  if  brick,  stone  or 
terra  cotta  is  used  on  the  outside,  but  by  none  of  these  method-  is 
one  absolutely  sure  of  preventing  saltpeter  spots  on  the  plaster 
which  is  put  directly  on  them.  It  could  be  avoided,  however,  by 
putting  on  furring  and  metal  lath  (Fig.  25),  but  this  is  an  expen- 


5??.:  wS-"ol,-V:  o £•& .-\srl5»T> 

,9  ti?;a.p 


J 


p-:ss 


fig.  23. 

sive  and  useless  method,  inasmuch  as  there  arc  now  on  the  market 
compounds  which,  if  properly  applied,  will  do  a\va>  with  this  bad 
feature  with  which  the  architect  lias  had  to  contend  heretofore. 
It  may  be  said  here  that  this  also  applies  to  the  si  riking  through  ^\ 
the  saltpeter  when  hollow  tile  is  used  for  walls,  ceilings  and  parti- 
tions. 

Damp-Proofjng. — In  the  treatment  of  walls  for  damp-resist- 
ing in  order  to  prevent  moisture  t  pom  coming  I  lirough  and  avoiding 
saltpeter  stains  and  to  eliminate  the  expensive  furring  processes — 
i.  e.,  do  away  with  the  air  space  there  should  be  pu1  oil  a  double 
coating  of  the  damp-resisting  compounds  before  the  plastering  La 
done;  the  first  coat  after  the  roof  is  on,  and  the  second  coat  before 
the  plastering  is  done.    After  the  plaster  is  on  it  will  form  a  per- 


146 


M  VSONEY 


oianeni  bond  over  this  application,  and  has  been  found  to  be  very 
efficacious  in  preventing  saltpeter  stains,  which  are  so  unsightly 
on  fireproof  buildings.  In  building  the  parapet  walls  (Fig.  26), 
the  roof  side  should  be  given  a  coat  of  liquid  cementations  paint. 
This  latter,  which  is  excellent,  will  prevent  any  dampness  from 
creeping  through  the  walls  and  down  to  the  ceiling  of  the  top  floor. 

When  the  above  mentioned  damp-resisting  paint  is  put  on 
the  walls  it  should  also  be  put  on  the  under  side  of  the  roof.  En 
this  way  an  almosl  continuous  damp-proofing  is  put  on  these 
walls,  which  will  be  found  to  serve  the  purpose  very  well. 

It  might  be  mentioned  here  that  the  walls  of  interior  vaults 


FIG.   24. 

for  the  storage  of  documents,  valuables,  etc.,  can  be  treated  with 
one  of  these  damp-resisting  compounds,  and  in  this  way  do  away 
with  the  ordinary  mildew  which  forms  in  such  air-tight  places. 
However,  if  these  are  thoroughly  dried  out  by  salamander  and  are 
completely  enclosed  in  the  building  there  should  he  no  such  danger. 

It  will  he  necessary  in  using  these  compounds  and  so-called 
paints  that  they  he  alkali  proof,  so  that  the  lime  in  the  cement  and 
in  the  brown  coal  of  plaster  should  not  affect  them.  On  the  other 
hand,  they  must  contain  ao  tar,  for  the  reason  that  this  would  stain 
the  plaster  <>n  the  inner  surface  of  the  room. 

Chimneys  ajstd  Flues.  Grreai  <-;ire  should  he  exercised  in  the 
construction   of  chimneys  and  tin*-,  as  well   as  ventilating  ducts, 


M  \s<  INEY 


147 


m  the  building  of  hospitals.  The  latter  arc  not  so  important  'is 
their  function  primarily  is  to  convey  air,  and  any  leakage  in  them 
would  not  necessarily  be  of  greal  danger  excepl  in  contagious  hos- 
pitals. It  is,  then,  to  this  latter  class  of  buildings  that  it  would 
particularly  apply.  Chimneys,  flues  and  ducts  should  be  carried 
well  up  so  as  not  only  to  create  the  necessary  drafts,  but  in  order 
that  the  discharge  from  them  be  diluted  at  as  great  a  distance 
as  possible  above  the  habitable  parts  of  the  hospital. 

Except  in  very  large  hospitals,  from  500  beds  up,  in  which 
a   special  and  isolated   mechanical   plant    would   be   required    the 


FIG,   -•). 

construction  of  the  chimneys  from  the  main  boilers  should  be  given 
special  attention.  Such  chimneys  should  b<  built  for  at  leasl  h> 
or  oil  feel  of  t  heir  heighl  above  the  boiler  with  fire  brick,  and  under 
all  circumstances  should  be  built  with  an  air  space  from  top  to 
bottom  (Figs.  27  and  28).  With  a  little  care  and  ingenuity  this 
space  often  can  be  used  for  the  ventilation  of  the  boiler  room.  In 
the  case  of  separate  plants  for  lighting,  heating  and  mechanical 
purposes  in  the  larger  hospitals,  chimneys  are  ordinarilj  con 
structed  by  companies  specially  organized  for  this  work.  In  the 
case  of  vents  the  plastering  of  the  inside  of  the  vent  lines  i-  suffi- 
cient for  all  purposes.  The  lining  of  these  vents  with  other  ma- 
terial will  he  more  full)  dealt  with  in  another  chapter 


148 


MASONRY 


Roof. — As  a  rule  the  roof  should  not  be  of  a  slanting  charac- 
ter, for  the  space  which  is  under  this  portion,  and  which  is  usually 
an  attic,  can  be  better  utilized  for  practical  purposes  by  expending 
the  money  that  such  a  roof  would  cost  to  carry  up  another  story. 
In  this  case  an  ordinary  Mat  roof  would  be  put  on  to  this  addi- 
tional story.  Sightly  parapets  and  even  pediments  can  be  run 
over  the  top  and  made  artistic  while  serving  their  purpose.  These, 
however,  are  matters  which  must  be  left  entirely  to  the  good  sense 
and  judgment  of  those  in  charge  and  to  the  architect  employed. 

Purring. — In  fireproof  buildings  there  should  be  no  furring 
except  of  a  fireproof  character.  The  hollow  brick  now  on  the  mar- 
ket is  little  or  no  better  than  the  ordinary  common  brick,  so  far  as 
furring  is  concerned.    The  lining  up  of  all  outside  walls  with  gyp- 


fig.  26. 
-inn   products  is  also  too  expensive  and  is  not  absolutely  trust- 
worthy, as  they  are  all  subject  to  absorption. 

A  word  might  be  said  here  as  to  the  general  aspect  of  the 
exterior  of  the  building.  As  stated  before,  this  should  be  neat  in 
design  and  as  artistic  as  possible.  Some  artistic  ability  must  oe 
displayed  in  even  the  simplest  of  these  structures,  with  no  more 
expenditure  than  an  ordinary  building  would  cost.  It  is  wrong 
to  suppose  thai  environment,  especially  the  exterior,  has  no  effect 
whatever  upon  the  patient.  For  a  hospital  well  Located  with  lawns 
and  trees  about  it,  and  having  the  general  appearance  of  a  home- 
like institution,  or  even  a  large  residence,  will  often  attract  people 
who  would  under  no  other  circumstances  go  to  such  a  place.  Tt 
has  also  its  mental  effect  as  well  upon  the  public  at  large. 

The   material    for   the   exterior   of   such  buildings,   as   stated 


m  \.S0NR3 


14!) 


above,  must  be  left  entirely  to  the  architect,  bul  tinder  no  circum- 
stances, except  as  stated  for  general  artistic  effect,  should  any 
vast  sums  be  expended  on  this  pari  of  the  building.    All  unneces- 


no.  li 


1 


,\\\\V\\V.\\-] ,;  N 


ssssssssss  - 


§l\\\\\\\\\\\\\\^ 


FTG.   ll 


sary  embellishments  in  the  way  of   balconies,   turrets,   dormers, 
should  be  strictly  avoided  except  in  exceptional  cases. 

To  sum  up.  the  masonry  of  a  hospital  should  be  the  best  and 
the  simplest;  should  be  damp  resisting,  and  in  appearance  artistic, 
but  not  ornate. 


CHAPTER  XII. 


CARPENTRY. 

iii  giving  the  details  <>1  the  carpenter  work  accessary  in  hos- 
pitals it  must  be  borne  in  mind  thai  all  classes  of  such  hospitals 
must  be  taken  into  consideration;  those  which  are  wholly  fireproof; 
those  which  have  fireproof  construction,  and  whose  interior  trim, 
etc.,  are  of  wood;  and  those  in  which  the  entire  construction,  ex- 
cepl  the  outside  walls,  is  of  wood:  and  those  which  are  built  com- 
pletely of  wood.  Of  the  latter  class  no  special  mention  need  be 
made,  and  the  items  here  given  will  cover  all  cases  that  may  arise. 


fig.  j:. 


Those  portions  of  carpentry  work-  which  are  not   described  here 
will  be  fully  treated  elsewhere. 

Floors. — The  wooden  floor  construction  used  in  buildings 
would  apply  to  hospitals,  and  i<  such  as  is  used  in  ordinary  prac- 
ti-«.  Where  floors  of  wood  are  laid,  extreme  care  must  be  exer- 
cised to  use  an  approved  system  of  deafening,  so  that  no  sounds 
will  travel  from  one  story  to  another.    The  old  method  of  plaster- 


...  .....  ■  .........  ■  ■  ■  ...ivy  .  ...-...-.,.-.■  _..-.-_  ..w.^j..-. 


FIG.  30. 

ing  and  back  plastering  I  Fig.  29),  or  putting  on  a  false  construc- 
tion for  the  ceiling,  and  leaving  the  floor  joists  to  support  the  floor 
only,  will   not   suffice   (  Pig.  30). 

The  deafening  itself  must  be  taken  care  of  between  the  rou^h 


CARPENTRY 


l.")! 


floor  and  the  finished  Moor,  and  must  be  of  such  character  thai  it 
is  not  only  sound  proof,  I  ml  also  vermin  and  dusl  proof.  No  at- 
tempt will  be  made  here  to  describe  the  methods  of  deafening,  as 
there  are  many  such  in  use,  and  undoubtedly  all  architects  arc 
familiar  with  them.  One  method  is  illustrated  here,  however,  be 
cause  it  has  been  found  exceptionally  successful  and  is  probably 
the  simplest  in  form  and  application  (  Fig.  '■>]  ).     As  will  be  noted 


pig.  31. 

the  furring  strips  which  are  placed  over  the  deafening  are  not  on 
the  same  centers  as  the  floor  joists,  but  are  placed  about  one  inch 
from  them.  This  is  done  so  as  to  avoid  the  driving  of  nails 
through  the  strips  and  into  the  joists,  and  in  this  manner  making 
a  direct  path  of  travel  for  sound  or  the  principle  of  the  telephone. 
The  deafening  material  can  be  one  of  the  many  forms  now  in  use 
The  floors  for  the  different  portions  of  all  hospitals  have 
been  a  matter  of  dispute- for  many  years.  After  thorough  investi- 
gation the  authors  have  concluded  that  the  matter  is  one  which 
will  always  be  open  to  discussion;  that  the  methods  \'w  laying 
floors,  and  the  materials  for  same  herein  described,  are.  in  their 
estimation,  and  from  the  use  of  same,  the  best  fitted  for  their  re- 
spective purposes.  If  the  hospital  is  of  fireproof  construction, 
then  no  matter  what  the  floors  may  be,  whether  of  wood  or  one  of 


^°oS«.a<«e^.?p?ciAJ,£c^ 


I    !.    .    32.  ' 

the  many  compounds  now  on  the  market,  or  whether  of  cement. 
marble,  or  glass,  the  vital  poini  to  be  considered  is  nol  the  ma- 
terial primarily,  but  the  method  and  care  with  which  the}  are 
laid.  In  laying  wooden  floors  oxer  fireproof  floors  the  bevel  strips 
for  nailing  these  should  be  of  such  shape  thai  they  will  be  fin  ilj 
imbedded  and  remain  so  (Fig.  32).  There  are  probably  verj  few 
buildings  now  in  existence  in  which  the  laying  of  these  strips  lias 
been  done  with  ;in\  degree  of  care.  Too  often  they  give  rise  to 
creaking,  uneveiiness,  and  all  the  attendant  ills  of  wooden  floors. 
They  are  usually  laid  in  the  wet  concrete  and  a  deafening  of  cin- 
der concrete  put  between  them,  and  gallons  and  gallons  of  water 


L52 


CARPEXTRY 


are  absorbed  by  them,  immediately  causing  the  strips  to  swell, 
and  a  consequent  pushing  aside  of  the  concrete  itself  and  also  of 
the  deafening.  When  the  entire  mass  is  dry,  and  the  strips  have 
dried  out,  as  they  necessarily  must,  they  are  found  to  be  loose. 


FIG.  33. 

We  paint  the  back  of  trim  for  buildings  so  that  it  will  not 
shrink,  check  or  warp.  We  give  priming  coats  of  paint  to  almost 
every  part  of  a  building,  even  including  the  iron  work,  so  that  no 
harm  may  come  to  these  portions  of  the  work,  but  in  very  few 


pig.  34. 

instances  <l<>  we  ever  give  any  attention  to  the  floor  strips.  These 
should  either  be  primed  thoroughly  or  oiled,  or  should  be  treated 
with  some  of  the  many  fireproof  compounds  now  on  the  market: 
they  should  either  be  thoroughly  creosoted  or  be  given  a  good  coat 
of  tar  or  asphalt.     In  laying  finished  floors  on  these  strips  after 


C  LRPENTR1 


153 


the  deafening  is  put  between  them,  extraordinary  care  should  be 
taken  so  that  the  work  is  done  in  the  best  manner.  The  "driving 
up"  of  the  ordinary  tongued  and  grooved  flooring  is  too  often 
carelessly  done,  and  in  consequence  the  floors  arc  not  as  perfed  as 


fig.  35. 

they  should  be.  H  is  needless  to  say  thai  for  wooden  floors  of  this 
character  nothing  but  the  close-grained  wood  should  be  used, 
maple  having  been  found  the  besl  for  the  purpose. 

Coves.— If  the  floor  coves  to  which  these  arc  laid  arc  to  be 
of  wood,  the  joinl  between  the  floor  and  the  cove  should  be  care- 
fully made,  so  thai  there  Is  no  possibility  for  the  Lodgmenl  of 
dust.    The  mailer  of  coves  will  be  treated  separately,  bu1  a  word 


154 


CARPENTRY 


here  in  regard  to  the  floor  cove  will  not  be  amiss.  If  these  are 
made  of  wood,  as  stated,  one  of  the  designs  as  shown  in  Figs.  33, 
34,  35,  36  can  be  used.  The  method  shown  in  Fig.  37,  of  putting 
the  cove  into  the  room  and  a  quarter-round  from  the  cove  to  the 
floor  is  absolutely  wrong,  as  the  primary  objeel  of  the  cove  is  de- 


ne .'!';. 
feated,  making  a  sharp  corner  for  the  lodgment  of  dust  and  parti- 
cles. 

The  mutter  of  floor  construction  with  materials  other  than 
mentioned  will  he  treated  separately  under  their  respective  heads, 
and  will  he  found  in  the  chapter  on  marble,  mosaic,  tile,  etc. 


CARPENTRY 


155 


Doors,— With  but  few  exceptions  for  some  tune  to  come,  the 
ordinary  wooden  door  now  in  use  in  all  hospitals  will  be  the  model, 
as  very  little  attention  will  be  s?iven  to  developments  along  this 
line.  While  the  paneled  door  for  artistic  effecl  may  be  the  mosl 
desirable  in  institutions,  it  cannot  of  necessity  be  the  best,  owing 
to  the  multitude  of  places  for  the  lodgment  of  dust. 


FIG,   Oi 


The  section  of  a  door  shown  in  Pig.  38,  where  the  mold  has 
ai]  outfacing  surfaces,  and  where  the  lodgmenl  of  dust  is  reduced 
to  a  minimum,  would  be  the  besl  form  to  use,  if  paneled  doors  are 
necessary  in  the  estimation  of  either  the  archited  or  the  commit- 
tee which  is  building  the  hospital,  from  .1  purely  esthetic  stand- 
point The  development  which  hospital  construction  has  made 
has  necessitated  the  stud5   b5    manufacturers  of  the  entire  inside 


L56 


CARPENTRY 


finish  to  such  an  extent  that  there  lias  been  put  upon  the  market 
a  door  without  panels,  made  in  such  a  manner  that  it  is  more  dura- 
ble than  any  other  kind.  This  is  either  a  five  or  seven-ply  door, 
or  a  cored  door  (Figs.  :!!>  and  40).     The  finishing-  of  these  doors 


fig.  o 

with  oak  or  any  hardwood  veneers,  and  the  artistic  application  of 
fillers  and  varnishes,  make  them  far  superior  to  anything  so  far 
attempted  in  this  line,  both  as  to  merit  for  the  purpose  intended, 
as  well  as  artistically. 


FIG.   39. 

Iii  -nine  hospital-  a  particular  effort  has  been  made  to  elimin- 
ate all  angles,  not  only  in  doors,  hut  at  all  other  points.    No  doubt 


CARI  ENTRY 


L57 


there  is  an  advantage  in  this,  if  it  can  be  accomplished  without 

detriment  to  the  appearance  of  the  r ls,  and  provided  also  that 

it  does  not  greatly  increase  the  expense  of  construction. 

There  is  a  partly  scientific  idea  which  accounts  for  this 
feature — dust  contains  microbes;  irregularities  upon  the  surfaces 
favor  the  accumulation  of  dust;  microbes  cause  disease,  hence 
we  must  prevent  any  possibility  of  dusl  accumulation  in  order  to 
prevent  the  collection  of  microbes,  thus  eliminating  the  transmis- 
sion of  disease.  Superficially  this  sounds  logical,  hut  we  have 
omitted  one  of  the  important  factors;  it  requires  contact  with 
these  micro-organisms  to  cause  disease,  and  as  they  are  not  good 
travelers,  they  would  require  several  centuries  to  progress  from 
the  irregularities  to  the  patients.  Consequently  such  irregulari- 
ties cannot  of  themselves  be  considered  as  harmful. 

The  primary  reason  for  making  as  few  angles  as  possible 
where  dust  could  collect  is  one  of  cleanliness.     No  one  can  doubt 


fig.  40. 

that  a  door  without  molds  is  much  to  be  preferred  on  this  -core 
alone. 

In  fireproof  hospitals,  however,  it  seems  thai  some  form  of 
door  should  be  put  in  that  would  entirely  isolate  the  rooms  from 
the  corridor,  and  also  from  one  another,  in  such  a  manner  that  If 
a  tire  started  in  any  given  space  it  could  be  confined  to  this  space 
absolutely.  This  would,  of  course,  necessitate  the  elimination  of 
the  wooden  door  entirely;  also  the  trim  and  wood  transom  with 
the  ordinary  glass.  There  are  now  on  the  market  metal-clad 
doors,  which  are  made  very  artistically,  with  or  without  panel. 
The  transom  can  be  glazed  in  wire  glass,  and  while  this  would  not 
be  a  fire  preventive,  it   would   he  a   lire   retardent.     These  metal- 


l.> 


C  \i;i-kntky 


clad  doors  are  made  of  wood  inside,  covered  with  sheet  metal  and 
finished  to  resemble  an  ordinary  wooden  door  (Fig.  41).  In  the 
Baltimore  and  San  Francisco  fires  these  doors  were  found  to  be 
thoroughly  capable  of  excluding  fire  from  given  spaces. 


FIG.    41  . 
Si  cti  m   Eli  vatii  m. 

The  efficiency  of  these  doors  to  exclude  fire— in  other  words, 
their  fireproof  qualifications — is  due  to  the  fad  that  they  arc 
seamless.  The  rather  surprising  point  in  favor  of  them,  aside 
from  their  fin-  n>-is1 \\v*  qualities,  i>  the  fact  that  they  are  no  more 


cai;im:.\  ri;v 


159 


expensive  than  good  hardwood  doors.  They  can  be  put  in,  either 
where  single  or  double  action  doors  are  used  ordinarily.  Their 
particular  usefulness,  however,  manifests  Itself  in  the  closing  off 
of  all  stairwells,  elevator  shafts  and  the  like  Such  door-  in  parti- 
tions between  elevator  shafts  surrounded  bj  stairways  where  there 
is  positive  isolation  is  of  particular  advantage,  of  which  an  illus- 
tration is  given  here  (Fig.  42).     As  will  be  seen  on  the  plans  for 


FIG.  42. 
Metal  Clad   Partition. 

model  hospitals,  illustrated  in  this  volume,  this  would  absolutely 
cut  off  the  stairwell  and  elevator  shaft  from  corridors,  and  do  so 
in  a  fire-resisting  manner. 

However,  if  there  is  an  objection  to  this  method  of  surround- 
ing such  spaces,  another  may  be  employed,  which  is  probably  as 
efficacious,  although  it  would  not  be  as  economical  namely.  1  * > 
make  angle  iron  frames  in  the  entire  opening.  The  frames  can  be 
divided,  as  is  shown  in  the  illustration  (Fig.  4.*'>),  with  black  iron 
sheets  riveted  on,  and  having  the  doors  made  of  angle  iron  and 
tilled  with  wire  glass  and  black  iron  panels.  The  iron  panels  rivet 
i'<\  on,  would  of  course,  be  much  more  costly  than  the  metal  covered 
door,  and  while  it  might  be  sightly,  il  is  doubtful  whether  it  would 
give  the  pleasing  effect  of  the  latter. 

It   is  an  absolute  necessity  that  the  double  action  door  be  em 
ployed  in  every  possible  instance.    This  is  especially  true  of  -paces 
that  are  used  continuously.     Where  double  action  doors  are  used, 
and  where  such  door-  are  single  instead  of  in   pairs,  care  should 


1G0 


(  AI.'PKNTRY 


be  taken  that  glass  be  put  into  the  upper  portion,  as  shown  in 
Fig.  38,  to  prevent  the  possibility  of  collisions.  This  can  be  either 
chipped  or  maze  glass.  Where  persons  are  coming  from  opposite 
directions  to  go  through  such  a  doorway,  a  shadow  on  the  glass 
gives  warning  of  the  approach  of  either  one  to  the  other. 

Door  frames,  excepl  in  rare  instances,  should  not  be  incor- 
porated into  the  building.  Where  they  are  put  in,  and  in  such 
instances  as  it  is  impossible  to- put  in  a  splay,  they  should  be  per- 
fectly plain  and  can  be  metal  clad  as  for  doors.  In  all  other  in- 
stances the  jamb  should  be  splayed,  as  shown  in  Figs.  44  and  45. 
The  head  need  not  be  splayed,  however,  as  it  is  somteimes  impos- 


1  f, 

^ 

/        ^ 

S' 

1 

I 

\ 

3 

FIG.  43. 
Vngle  Iron  Partition. 

si  1  tie  to  do  this  on  account  of  lack  of  head  room,  owing  to  con- 
structive details.  Such  a  head  is  shown  in  Fig.  46,  the  jambs 
being  -played,  leaving  as  little  space  as  possible  for  a  bed  mold, 
which  can  also  be  of  fire-resisting  material,  as  described  and 
shown  (Figs.  47  and  48).  The  manner  of  putting  in  base  blocks 
to  catch  floor  coves  is  shown  in  Fig.  49. 

Transoms. — In  cases  where  transoms  are  hung  over  doors, 
the  same  care  can  be  taken  in  avoiding  material  that  will  burn, 
and  as  stated  before,  these  can  also  be  of  metal-clad  material,  or 
of  angle  iron  frames,  and  have  wire  glass.  It  would  be  well  if 
some  method  could  be  incorporated  by  which  these  transoms,  in 
case  of  fire,  could  be  automatically  closed.     Transoms  should  be 


CARPENTRY 


Kil 


hung  in  such  manner  as  to  facilitate  automatic  closing,  but  it'  this 
is  not  done,  the  center-hung  transom  is  preferable  (this  to  be 
operated  by  the  ordinary  transom  Sift),  as  it  augments  ventila- 
tion (Fig.  41). 

Windows. — In  the  treatment  of  windows  for  liospitals  it  is 
not  necessary  to  go  into  detail  as  to  the  methods  of  installation, 
but  attention  is  again  called  to  the  fad  that  the  fireproof  window 
frame  sash,  either  of  the  all-metal  variety,  or  of  the  metal-clad 
variety,  can  be  used.    While  the  source  of  fire  so  far  as  the  win- 


pig.  44. 

Door  head  with  nit.  trim  in  room. 

dows  are  concerned  is  in  mosl  cases  from  outside  the  building 
itself,  the  same  care  and  attention  to  the  poinl  here  mighl  be 
questioned,  but  so  long  as  fireproof  bospitals  are  being  construcl 
ed,  and  the  cosl  is  not  unreasonably  in  excess  over  the  all  wood 
construction,  there  can  be  no  valid  excuse  for  not  making  ever} 
thing  in  the  construction  of  the  hospital  as  Dearly  fireproof  or  fire- 
resisting  as  possible. 

The  window  sash  should  be  hung  in  chains  or  in   steel   tapes 


162 


CAEPENTBY 


over  good  pulleys.  The  latter  should  not  have  less  than  two  and 
a  half  inch  wheels,  and  should  be  of  either  the  smooth  running, 
pin-bearing  type,  or  ball-bearing,  to  avoid  squeaking,  which  is  one 
of  the  principal  causes  of  annoyance  to  patients. 

Above  the  second  story  all  windows  in  the  hospital  should  be 
of  such  type  as  are  advocated  by  ordinances  in  most  of  the  large 
cities  in  this  country,  so  that  all  the  cleaning  can  be  done  from  the 
inside;  the  different  patternsof  these  on  the  market  are  innumer- 
able. Care  should  be  taken  in  selecting-  only  those  which  have 
this  advantage  of  easy  cleaning,  combined  with  simplicity.  Too 
much  stress  cannot  be  laid  upon  this  latter  point,  as  some  windows 
are  so  complicated  that  only  an  expert  can  operate  them.    Fig.  50 


mi;.  45. 
Door  head  with  i rim  in  room. 

and  Pig.  ol  show  windows  with  Hat  head  and  jambs  and  with 
splayed  head  and  jambs,  the  molds  being  similar  to  those  for  doors 
of  same  type. 

Finish. — The  inside  finish  of  the  entire  building  can  be  made 
i  ihe  metal-clad  form,  and  where  the  building  is  not  absolutely 


CAKI'KXI  RY 


16:3 


fireproof,  should  be  of  close-grained  wood,  if  possible,  and  it'  aot, 
should  be  of  oak,  well  filled  and  varnished  or  enameled,  as  will 
be  described  under  Painting. 

The  trim,  sonic  forms  of  which  arc  illustrated  here  (  Figs.  52, 
53,  54),  may  be  metal  dad  or  the  same  form  in  wood.  The  metal- 
clad  trim  can  be  made  to  represenl  any  wood  desired,  which,  in 
itself,  is  a  recommendation,  inasmuch  as  rooms  can  be  finished 
differently,  especially  those  for  private  patients,  and  a  differenl 
scheme  of  decoration  used  throughout  the  hospital.  In  putting  tin' 
trim  on  windows,  the  same  care  should  be  exercised  in  doing  away 
with  as  much  of  it  as  i>  possible.     There  should  he  no  wooden  sills 


i  io.  -hi. 

I »( ii  >r  head,  trim  in  n  ••mi.  square  head. 

in  the  building.    Either  a  splaj  should  he  used  with  a  corner  bead 

around  the  entire  window,  as  shown  in  Pig.  50,  «m-  there  should  be 
;i  Hat  sill  not  less  than  1  '  i  inches  in  thickness,  made  of  either  mar 
ble  or  some  variety  of  slate,  all  of  which  arc  obtainable  I  Pig.  51  ). 

If  possible,  there  should  be  no  base  in  the  rooms,  hut  the  cove 
in  the  wall  should  meet  the  floor  on  a  flush  line.  ;h  shown  under 
Floors.  If  th«'  floors  are  of  wood,  these  coves  could  be  made  with 
the  plaster  running  to  them,  or  cm:  lie  of  wood  also,  as  shown  in 
Figs.  33,  34,  35  and  36. 

Picture  Molds  in  all  rooms,  where  possible,  picture  molds 
can  he  run.  except  in  contagious   hospitals  and  in  children's  uos- 


164 


CARPEK  I  II Y 


pitals.  In  nil  other  hospitals  these  picture  molds  can  be  made  of 
the  metal-clad  material,  or  not,  as  desired,  there  being  so  Little 
it  would  make  no  material  difference  in  case  of  lire 

Partitions. — All  partitions  dividing  spaces,  such  as  in  cor- 
ridors and  other  rooms,  fan  be  made  to  follow  the  same  lines  as 
those  laid  down  for  stairwells  and  elevator  partitions. 

Stairs.-    In   the   non-fireproof    hospitals — that    is,    those   for 
smaller  towns,  where  it  is  not  expedient,  owing  to  lack  of  funds, 
or  for  other  reasons,  to  build  an  absolutely  fireproof  structure 
the  stairs  would  necessarily  be  built  of  wood,  but  even  such  stairs 


FIG.  47. 
Plan  of  doi  »r  withi  >ut  trim  in  n  »om. 

can  be  made  in  such  a  manner  that  they  are  to  some  extent  at  Leasl 
closed  off  from  the  remainder  of  the  building,  ami  protected,  pri- 
marily, so  thai  in  case  of  fire,  egress  from  the  building  can  be 
effected  by  them.  This  can  he  accomplished  by  using,  instead  of 
Ordinary  wood  lath,  the  wire  or  expanded  metal  lath,  with  cement 
plaster,   which,   while   it   would    in    no  sense   make   fireproof   stairs, 


carpentry 


165 


would  be  a  fire  retardent,  if  sufficient  stops  were  put  in  al  close 
intervals  on  the  heighl  between  the  studs.  This  is  ofteu  suffi- 
cient to  give  time  for  every  one  to  escape  I'nnn  a  building  of  this 
character,  should  the  occasion  arise,  h  is  to  be  supposed  that 
there  would  not  he  any  more  than  two  flights  ol  stairs  from  the 
top  to  the  lower  floor  in  any  hospital  of  wood  construction.  The 
surrounding  of  the  stair  well  by  a  brick  wall  would,  of  course,  be 
the  hest  method  to  employ,  no  openings  being  left  in  this  except 
the  windows  to  the  outside  rmd  the  doors  into  the  corridors,  these 
latter  being  double  action,  to  he  of  either  the  metal-clad  variety 
or  of  the  angle-frame  variety,  as  mentioned  herein. 


I  [Q.    18. 
Plan  "i  door  with   trim  in   room. 

In  fireproof  hospitals  little  need  be  said  of  the  stairs,  as  this 
feature  will  be  I'ul I \  covered  under  the  head  of  fireproofing,  bul  the 
method  employed  in  some  liospitals  of  making  the  entire  building 
fireproof,  with  the  stair  stringers  oi  iron  and  the  risers  also 
of  the  same  material,  and  then  putting  in  wooden  treads,  is  vicious 
and  to  be  deplored,  h  this  is  done  from  a  sense  of  economy,  even 
in  eight  or  ten  story  buildings,  it  is  inexcusable,  as  economy  should 
be  practiced  elsewhere  in  order  to  use  fireproof  treads  on  such 
steps.  If  it  is  t'oi  the  purpose  of  lessening  noise,  it  may  be  said 
here  that  if  a  hospital  is  properh   constructed,  and  the  stairs  are 


166 


CARPENTRY 


isolated,  as  is  demanded  in  most  of  the  large  cities  now.  such  an 
excuse  is  not  to  be  considered. 

In  genera]  it  may  be  said  that  too  little  attention  is  given  to 
tiic  matter  of  easy  runs  on  stairs.  In  order  to  make  them  so, 
landings  should  be  provided.  If  space  is  to  lie  sacrificed,  it  is 
usually  taken  from  this  portion  of  the  building.  Another  point  to 
he  mentioned  is  that  all  stairways  should  be  constructed  in  such  a 
position  as  to  have  outside  light. 

Porches. — In  non-fireproof  buildings  there  should  also  he 
huilt  large  verandas,  and.  if  possible,  these  should  in  ail  instances 
l»c  fireproof.  This  can  lie  done  very  cheaply  with  reinforced  con- 
crete, or  by  an  all-iron  method,  which  is  frequently  employed. 
From  these  balconies  there  should  lead  from  floor  to  floor,  and 


--' 

----- 

Tt-ooe:  Covr 

.    FIG.   49. 

Side. 

Showing  base  Mock  where  trim 


Front    Elevation, 
used  on  openings. 


to  the  ground,  a  wide  stairway,  so  that  a  patient  could  be  carried 
from  a  floor  where  a  fire  occurs  to  any  one  of  these  verandas,  and 
then  down  the  stairs  to  the  ground,  safely  and  rapidly  and  without 
dangerous  exposure.  Too  much  stress  cannot  he  laid  on  this  sub- 
ject of  verandas  in  such  hospitals;  in  fact,  this  may  apply  to  al- 
most all  hospitals,  whether  of  fireproof  or  non-fireproof  construc- 
tion, as  iu  many  instances  these  could  he  used  for  solariums  for 
convalescent  patients. 

Casks.  Special  care  should  be  taken  in  the  designing  and 
constructing  of  cases  for  pantries,  kitchens,  linen  closets,  instru- 
ments and  medicines.     Thev  should  be  made  in  such  a  manner  as 


CARPENTRY 


167 


to  be  susbtantial,  bul  should  not  be  in  large  sections,  nor  should 
they  be  permanent  fixtures,  but  in  all  instances  be  made  of  the 


ii.i    50. 
Sectii  m  in  rlc\  ati<  in  and  plan, 


"knock-down"  variety.     IT  it  is  necessary  to  clean  behind  them 
as  is  often  the  case,  or  there  is  anj  change  in  the  arrangement  of 


168 


CARPENTRY 


the  hospital  which  would  call  for  their  removal  to  another  loca- 
tion, such  conditions  could  be  met  with  the  greatest  facility.     It 


FIG.   51 . 
Sectii  hi  in  ele\  ation  and  plan. 

seems  that  it  would  be  a  very  feasible  plan  to  construct  these  case  - 
on  the  expansion   method,  as  is  employed   in  making  bookcases. 


CARPEN \u\ 


169 


They  could  then  be  made  at  all  times  to  meet  the  requirements  of 
the  hospital  in  its  development. 

No  specific  detail  can  be  given  for  such  cases,  nor  can  rules 
be  laid  down  for  their  exact  use;  this  must  be  left  entirely  to  the 
architect,  who  has  had  experience  in  designing  such  items,  so  that 


FTG.  .)_:. 
Trim. 

they  may  be  of  the  required  form  and  type  and  size.    There  are  qo 

two  instances  in  which  conditions  are  precisely  the  same,  for  much 
depends  upon  the  general  management  of  the  liospital  itself;  but 
this  need  not  preclude,  in  any  manner,  the  possibilities  of  the  ex 


Stops. 

pansion  system.  The  vital  point  t"  lie  considered,  however,  is 
thai  the  cases  should  l><-  of  the  simplest  lard,  so  constructed  thai 
they  are  readily  cleaned  from"  inside  and  outside,  and  that  in  all 
instances  they  he  regarded  not  as  pari-  of  the  building,  but  as 
accessories  or  furniture.  'This  may  not  seem  expedient  in  the 
building  of  pantries,  Ian  a  little  thonghl  on  the  subjed  will  show 


170 


CARPENTRY 


that  it  is  necessary  in  these  places  as  in  no  other  portion  of  the 
hospital. 

Lockers. — The   same   principle    follows    where    Lockers    are 


FIG.    .")-(-. 
Bed   moulds. 

"built  in."  Such  method  of  constructing  lockers  is t particularly 
to  be  condemned,  as  there  are  few  instances  where  these  built-in 
lockers  do  not  become  unsanitary,  even  with  the  best  of  care. 
They  cannot  be  constructed  by  the  ordinary  carpenter  in  such  a 


manner  as  to  be  irremovable  and  sanitary  at  the  same  time.  The 
only  Locker  worthy  of  consideration  in  any  hospital,  be  it  a  tire- 
proof  or  non-fireproof  building,  is  an  all-metal  one,  whether  this 


C  \i:i'i'.\T!;v 


171 


be  of  the  open  type — namely,  the  wire  mesh  type,  as  shown  in 
Fig.  55 — or  of  the  closed  type,  as  shown  in  Fig.  5G. 

All  of  these  have  their  advantages,  as  they  are  built  with  a 
view  to  ventilation  and  sanitary  conditions.    The  closed  type  form 

of  metal  locker,  known  as  the  "k ik-down"  type   (Fig.  56),  is 

probably  one  of  the  best  on  the  market  to-day,  inasmuch  as  it  can 
be  taken  apart  in  a  few  moments,  thoroughly  cleaned  or  renovated, 
and  put  together  in  the  same  space  of  time.  These  lockers' are 
made  with  the  enamel  burned  on,  which,  with  ordinary  care, 
should  last  for  many  years.  It  is  wrong  to  suppose  that  a  locker 
room  should  be  one  that  can  be  used  for  no  other  purpose  because 


pig.  56. 

it  is  dark  and  out  of  the  way.     M  is  as  necessary  to  have  sunlight 

and  ventilation   in  this  as  in  any  other  room   in  the  building;    in 

fact,  it  cannot  be  too  strongly  advocated   thai  this    be   the   rule 
rather  than  the  exception. 

Hardware. — It  is  not  necessary  to  go  into  a  lengthy  explana- 


\l-2 

CABPENTRY 


CHAPTER  XIII. 

FIREPROOFING. 

A  building'  which  is  made  of  fireproof  materia]  and  is  sur- 
rounded by  buildings  of  like  construction  is  the  mosi  desirable 
kind  for  any  purpose.  This  is  true  of  nil  hospitals,  hut  especially 
so  of  those  built  in  congested  localities.  However,  this  condition 
is  not  always  to  be  obtained.  The  primary  consideration  of  hav- 
ing a  hospital  isolated  as  much  as  possible  cannot  always  be  car- 
ried out,  so  that  as  an  extraordinary  precaution  such  buildings 
should  contain  a  minimum  of  combustible  material,  and  the  utmost 
care  should  be  exercised  in  the  incorporation  of  the  iireproofing. 
Fireproofing  is  a  very  much  abused  term,  for  ordinarily  it 
is  construed  to  mean  ''anything  that  does  not  actually  burn." 

There  is  undoubtedly  inferior  fireproof  material  on  the  mar- 
ket, but  this  must  not  be  entirely  charged  againsl   lie  manufac- 
turer, but  should  be  against  the  users  as  well.     The  demand  in- 
variably controls  the  supply  in  cases  of  this  kind,  and  there  are 
those  who  will  ever  be  prepared  to  supply  just  so  much  as  people 
will  pay  for  and  no  more.     Tile  floors  and  tile  partitions;  concrete 
floors  and  partitions  of  the  same  material;    or  partitions  of  some 
of  the  many  first-class  fireproof  material.-,  when   properly   made 
will  apply  to  all  of  the  possible  problems  which  could  arise.     The 
fault  is  not  in  the  principle,  but  the  mamier  in  which  it  is  applied. 
If  hospitals  were  constructed   with   speculative  intent  there 
would   be  some  excuse  for  slighting  this  important    feature,   but    it 
is  a  recognized  fact  that  this  is  not  the  intent  of  Mich  institution-. 
Again,  there  are  those  who  "build  only  as  well  as  they  are  com- 
pelled to  by  law,  or  by  rules  made  by  those  who  indemnify  in  case 
of  loss."      If  there   is  ;ni\    class  of  building  in   which   the--   faults 
are  to  be  avoided,  it  is  in  hospitals.     Fireproofing  in  such  institu 
tions  should  mean  all  that   the  word  conveys,  not   only   as  a  pro- 
tective measure  itself  for  the  building  and  for  the  patient-  within 
1h«.  building,  but  as  an  absolute  moral  obligation. 

Xo  one  can  doubt  the  efficiency  of  the  better  type-  of  fireproof 
construction.  The  term  in  itseh  that  is,  fireproofing  is  so  broad 
thai  it  is  almosl  useless  to  attempl  to  define  what  (ire  protection 


174  FIREPROOFING 

is,  and  the  subjecl  may  be  roughly  divided  into  three  classes  as 
follows  : 

First  The  organization  of  fire  companies,  which  are  usually 
maintained  by  the  public  Cor  the  protection  of  its  buildings. 

Second — The  construction  of  the  building  in  such  a  manner 
thai  it  will  resisl  and  withstand  the  effects  of  fire. 

Third — The  apparatus  which  is  usually  put  into  buildings,  but 
which  is  m>t  necessarily  a  component  part  of  them,  for  use  in  case 
of  fire. 

There  is  no  need  of  going  into  detail  concerning  the  first  of 
these  divisions,  for  very  evident  reasons,  and  anything  like  an 
exact  or  comprehensive  review  of  the  third  division  could  not  be 
made  in  a  book  of  this  kind.  In  this  latter  division  such  devices  as 
are  ordinarily  used  will  he  mentioned.  Of  these,  the  standpipe 
with  hose  extension  and  the  different  lire  extinguishers  of  chemical 
pattern  are  the  principal  ones. 

The  second  division — namely,  fireproof  construction  pure  and 
simple — in  its  many  phases  and  forms,  is  given  here  in  a  con- 
tracted form,  for  the  principles  involved  are  those  which  the  archi- 
tect ordinarily  would  follow  from  specification,-  written. for  such 
systems. 

We  find  many  hospitals  constructed  in  the  ordinary  manner 
without  the  least  attempt  towards  the  safety  of  the  patients  in 
case  of  fire.  In  these  every  precaution  is  taken  and  every  device 
known  to  the  professional  man  is  incorporated  for  the  care  of  such 
patients  during  operation  and  sul (sequent  residency  in  the  institu- 
tion, but  no  thought  is  given  to  the  fact  that  in  the  event  of  fire, 
and  the  panic  which  usually  follows,  instead  of  having  one  patient 
at  the  time  to  care  for,  they  all  must  be  handled  and  often  re- 
moved from  the  building  in  an  incredibly  short  space  of  time.  In- 
stitutions have  come  under  the  observation  of  the  authors  which 
have  been  considered  model  in  every  respect,  and  which  did  not 
have  the  semblance  of  a  lire  escape  or  even  a  fireproof  porch,  or, 
for  that  matter,  a  porch  of  any  character,  to  which  patients  could 
he  removed  and  then  taken  to  the  ground.  In  many  of  these  there 
was  no  way  of  egress  whatever  except  by  one  narrow  stairway. 
It  is  safe  to  say  that  over  seventy-five  per  cent,  of  the  hospitals 
now  in  existence  are  of  this  character  and  type. 

It  is  peculiarly  characteristic  of  municipalities  that  regula- 
tion- are  made  for  theaters  and  even  for  office  buildings,  as  !<) 
their  safeguarding  of  the  public,  when  in  buildings  of  this  char- 
acter the  people  are  at  leasl  able-bodied  and  capable  of  taking  care 
of  themselves,  even  in  time  of  panic,  whereas,  except  in  the  largesi 


FIREPROOI  I  X « .  1  i  ~) 

cities,  there  is  no  provision  whatever  made  for  such  safeguarding 
of  those  who  are  entirely  helpless  in  case  of  fire. 

Fireproof  Material.— Materials  of  this  character  such  as 
will  not  themselves  bum,  will  resist  the  action  oi  fire  and 
X^rotect  the  structural  parts  at  the  same  time.  An  example  of  this 
will  suffice.  Cast  iron  will  not  burn,  bul  under  the  action  of  fire 
will  bulge  and  warp  and  thereby  cause  greal  damage,  even  to  the 
extent  of  the  wrecking  of  a  building. 

There  are  two  ways  by  which  fire  spreads  over  an  extended 
area,  horizontally  and  vertically.  To  prevenl  the  horizoutal 
spread,  all  walls  and  partitions  should  be  buill  of  incombustible 
and  fireproof  material,  and  any  doors  or  windows  in  these  walls 
should  be  equipped  with  fire-resisting  or  entirely  fireproof  de- 
vices. Fires  which  progress  in  other  directions  are  overcome  by 
building  the  floors  of  fireproof  material  and  making  them  con- 
tinuous. The  stair  wells,  elevator  shafts,  pipe  slots  and  other  con- 
tinuous openings  in  a  vertical  direction  should  be  buill  with  brick, 
tile  or  concrete  walls,  thus  isolating  them  respectively.  AM  open- 
ings in  these  shafts  should  have  fireproof  doors  or  windows,  as 
the  case  may  be.  It  must  be  borne  in  mind  that  not  only  the  shafts 
themselves  are  to  be  built  of  fireproof  material,  and  the  openings 
protected  as  stated,  but  that  every  part  of  such  portions  of  the 
building  must  be  treated  likewise. 

The  materials  for  fireproofing,  the  method  of  installing  th  >se 
materials  into  buildings,  and  the  necessary  devices  aside  from 
those  that  have  already  been  mentioned,  are  of  great  variety. 
These  include  floors  and  partitions  of  tiie,  concrete,  plaster  and 
expanded  metal  in  its  different  treatments.  Math  has  its  various 
ramifications  and  methods  of  installation.  The  manner  in  which 
these  are  taken  up  in  this  volume  does  not  imply  that  they  are  to 
be  so  ranged  as  totheir  respective  merits. 

Concrete.  It  will  he  necessary  to  state  in  connection  with 
concrete  construction  that  the  various  systems  will  not  he  de- 
scribed for  two  reasons:  First,  there  is  such  a  multitude  of  these 
and  th"  variations  are  so  ureal  that  it  would  he  impossible  in  i 
volume  of  this  kind  to  go  fully  into  them,  nor  is  it  accessary  to 
do  so,  except  as  illustrating  the  methods,  a-  the  manj  texl  books 
on  this  subject  and  the  catalogues  of  the  individual  system.*  fully 
describe  them.  Second,  the  requirements  <>!'  municipalities  pre 
elude  the  possibility  of  describing  anj  system  .it  length  which 
would  fulfil]  all  building  laws,  a-  there  are  such  vasl  variations  in 
these  laws.  It  may  he  stated  here  in  reference  to  the  second  of 
these  conditions  that  it  is  nol  safe  to  follow  such  building  require 
ments,  as  they  are  usually  far  behind  the  times  as  regards  con 


17<)  FIREPROOFING 

struction,  and  ordinarily  arc  made  by  men  with  no  technical 
knowledge  which  would  enable  them  to  draw  up  the  proper  speci- 
fications. 

Moreover,  when  building  laws  arc  made  and  passed  it  takes 
considerable  time  tor  Lhem  to  be  enacted,  and  by  the  time  they 
are  enforced,  improvements  will  have  been  made  which  render  the 
requirements  in  many  cases  obsolete.  In  other  words,  progress  in 
this  form  of  construction  is  so  rapid  that  a  year  will  make  a  vast 
difference  in  the  form. 

Concrete  is  beyond  the  experimental  state  as  a  building  ma- 
terial so  far  as  its  reinforced  qualities  are  concerned.  As  in  the 
selection  of  all  other  material,  so  here  extreme  care  must  be  exer- 
cised  in   the  choice   of   system. 

Protection. — Protection  of  steel  in  this  form  of  work  is  of 
vital  importance  and  must  he  given  more  than  ordinary  attention. 
In  no  instance  whatever  should  there  he  less  than  one  inch  of  con- 
crete at  any  point  for  such  protection,  as  mos!  of  the  failures 
which  have  occurred  in  concrete  construction  have  been  due  to  the 
fact  that  proper  care  had  not  been  given  to  this  part  of  the  work. 

One  of  the  important  advantages  of  concrete  construction, 
where  the  steel  is  properly  encased,  is  the  protection  of  the  metal 
from  corrosion,  hi  this  connection  it  may  he  stated  thai  the  use 
of  cinder  concrete  is  not  to  he  recommended,  for  in  the  best  form 
of  construction  in  this  manner  there  are  hound  to  he  impurities  in 
the  cinders  which  naturally  disintegrate  the  iron.  This  i.-  par- 
ticularly true  of  the  sulphur  which  is  left  in  them  by  improper 
combustion.  Gas  pipes  and  electric  conduits,  water  pipes  and 
other  iron  ways  nave  been  known  to  become  disintegrated  to  such 
an  extent  as  to  cause  serious  leaks,  and  by  repeated  experiments 
it  has  heen  found  that  this  was  due  to  the  properties  of  the  cinders 
themselves. 

It  is  not  safe  to  suppose  that  when  quantities  of  this  ma- 
terial are  put  into  a  building  that  care  will  he  taken  in  selecting 
only  such  as  are  absolutely  and. perfectly  burned,  nor  can  allow- 
ance he  made  for  the  intelligence  of  workmen  in  throwing  out  such 
materia]  as  is  not  fit  to  he  put  into  the  work.  It  need  not  he  stated 
here  that  intelligence  has  much  to  do  with  any  form  of  concrete 
construction,  for  unless  a  good  superintendent  is  put  on  the  work 
there  is  liability  of  the  work  being  done  in  a  manner  that  will 
cause  trouble  later.  While  good  concrete  construction  has  been 
found  to  1*11 1  ti  1 1  all  the  requirements  of  Greproonng,  it  i-  usually 
put  in  by  unskilled  labor,  and  this  would  of  itself  necessitate  ex- 
traordinary care  on  the  part  of  the  superintendent,  beyond  what 
would  he  called  for  in  some  other  forms  of  construction.     While 


FIREPR00F1NG  177 

this  argument  applies  forcibly  in  this  instance,  il  may  be  stated 
generally  that  while  the  intelligence  of  the  average  workman  is 
not  doubted  in  the  least,  the  interest  lie  lakes  in  his  work  is  not 
such  that  he  would  discriminate  as  to  the  methods. 

Deafening. — What  bas  been/stated  in  reference  to  cinder  con- 
crete and  the  disintegration  of  pipes  applies  nol  onlj  to  cement 
construction  itself,  but  also  to  any  form  of  construction,, be  it  hol- 
low tile  or  concrete,  where  the  deafening  of  cinders  is  put  in  be- 
tween floor  strips,  as  illustrated  in  Figs.  32,  67  and  84. 

There  are  several  methods  of  deafening  which  are  fully  as 
good  as  cinder  concrete,  although  none  of  them  has  the  qualifica- 
tion of  cheapness  of  the  latter.  One  of  these  is  the  use  of  mineral 
wool.  This  is  not  alone  admirable  sound  proofing  material,  for 
which  it  is  extensively  used,  but  it  also  furnishes  the  greatesl  pos- 
sible protection  from  the  heal  in  summer  and  the  cold  in  winter: 
in  other  words,  it  has  the  insulating  qualities.  It  is  vermin  proof, 
being  made  from  slag  through  which  a  jet  of  steam  has  been  blown 
at  high  pressure.  There  is  fiber  on  the  market  also  which  is  put 
on  in  quilt  form  and  which  will  not  burn.  These  fibers  also  have 
both  insulating  and  deafening  qualities. 

Of  those  deafeners  which  are  not  fireproof  no  particular  men- 
tion need  be  made,  but  inasmuch  as  the  floors  which  are  put  over 
them  are  usually  of  wood  and  are  in  themselves  not  fireproof,  this 
would  not  preclude  their  use  in  so-called  fireproof  buildings  where 
such  floors  are  used.  While  these  are  not  strictly  ti reproof,  thera 
is  no  particular  disadvantage  in  using  them  except  from  the  point 
of  view  that  in  a  fireproof  building  everything  should  be  fireproof. 

Cost. — The  cost  of  systems  to  be  installed  depend-  wholly 
upon  local  conditions.  If  terra  cotta  and  clay  products  are  aol 
available,  and  crushed  stone  or  crushed  slag,  or  washed  river 
gravel,  are  available,  the  reinforced  concrete  construction  would 
be  the  best  to  use.  However,  it'  the  Latter  materials  are  nol  avail- 
able, and  the  former  are  at  a  less  cost,  such  facts,  of  course,  would 
determine  the  system  to  be  recommended. 

PARTI  riONS. 

Plaster  Blocks. — The  use  of  plaster  partitions  when  the  ma- 
terial is  of  plaster  of  Paris  is  not  to  be  considered  fireproof,  bias 
feer  blocks  and  plaster  run  in  forms  are  used  in  fireproof  buildings, 
but  they  will  not  withstand  the  action  of  either  fire  or  water.  The 
absorption  of  water  in  such  material  is  from  -b>  to  50  per  cent,  of 
their  weight  when  in  dry  form.  When  exposed  to  heat,  in  COM 
parison  with  terra  cotta,  brick  or  concrete,  thej  are  nol  to  be 
considered.  The  plaster  calcines  and  when  wet  immediately  pow- 
ders, so  that  in  case  of  fire  if  such  partitions  or  even  floors  were 


178 


FIREPROOFING 


subjected  to  heat  and  a  stream  of  water  thrown  upon  them  they 
would  quickly  be  wrecked.  The  drying  out  of  such  blocks  is  very 
slow,  as  they  must  be  thoroughly  soaked  before  they  are  set. 
While  this  same  objection  might  be  raised  concerning-  tile  and  con- 
crete, it  must  he  borne  in  mind  that  the  drying  out  of  both  of 
!  hese  is  very  rapid. 

Steel  Studs. — The  form  of  partition  with  steel  studs  and 
furring  Tor  fireproofing  are  both  inexpensive  and  practical,  as  in 
this  method  of  fireproofing  a  channel  bar  is  used,  and  upon  this 
is  pui  expanded  or  wire  metal  lath,  and  both  sides  of  this  are 
heavily  coated  with  hard  plaster  (Fig.  L54A).    If  a  hollow  partition 


FIG.    >)l 


i>  desired  these  channels  are  taken  in  width  of  three  inches  and 
up.  If  a  solid  partition  is  wanted,  one  to  tw.o  inch  steel  studs  are 
used. 

Blocks  made  of  plaster  of  Paris  and  of  gypsum  have  the  same 
objection  as  stated  under  the  heading  of  plaster  blocks  namely, 
their  disintegration  under  fire  and  water.  These  are  built  in  either 
hollow  or  solid  partition  form  ami  have  one  particular  recom- 
mendation,  and  that  i>  thai  they  can  be  run  or  built  smoothly  and 
need  bu1  a  finishing  coat  of  plaster. 


PLBEP'ROOFIKG 


17:» 


Tile. — As  far  as  practical  building  material  for  partitions  is 
concerned,  tile  has  been  found  to  be  the  most  advantageous,  botb 
on  account  of  its  lightness,  and  the  fad  that  it  is  absolutely  fire 
proof.     There  are  two  forms  of  this  partition,  as  shown  in   F'igs. 
57  and  58 — namely,  the  "hook  tile  and  what   is  commonly  tern  ed 


mmmmmzm 


seJfeiigaBfegssaigggaiS  -<'-\'-i-^'/--<^-''^"'^i--?'r'-->y,r^T 


FIG.  58. 

hollow  blocks,  all  of  which  will  be  treated  more  fully  under  fire- 
proofing  with  clay  materials. 

Safes  and  Vaults. — In  ail  hospitals,  be  they  fireproof  or  non- 
fireproof,  safes  and  vaults  should  be  provided.  In  hospitals  it  is 
necessary  to  make  and  keep  records,  and  these  must  of  necessity 
be  well  protected.  It  is  desirable  to  have  a  vault  with  safe  in  the 
office,  as  shown  elsewhere  in  this  volume,  and  in  the  basement 
supporting  this  a  storage  vault  for  back  records  and  account 
books.  The  vault  on  the  firsl  floor  is  for  the  purpose  for  which 
such  are  usually  intended,  but  should  have  sufficient  shelves  and 
eases  to  admit  of  the  handling  of  the  records,  files,  etc. 

It  has  been  found  that  in  the  event  of  severe  fire,  with  walls  of 
about  18  inches  in  thickness  built  up  of  good  hard  brick,  in  which 
there  had  been  no  iron  work  whatever,  results  were  ver\   satisfac 


L80 


i- 1 ii i.i  Kool  i:*o 


tory.  li  is  necessary  in  building  such  vaults  that  they  rest  upon 
their  own  foundations  in  the  basement.  It  is  recommended,  how- 
ever, that  an  air  spare  be  put  hetweeti  the  outer  and  inner  walls, 
as  shown  in  Fig.  59.  For  reasons  already  stated,  vaults  built 
entirely  of  concrete  would  be  as  good  as  those  of  either  hollow  iile 
or  brick.  In  no  case  whatever  should  such  inclosures  be  built  of 
plastic  material,  such  as  has  been  described. 

In  building  vaults,  care  should  be  taken  thai  all  of  the  work 
be  laid  in  cemenl  mortar,  and  that  this  he  done  in  the  most  careful 
manner.  It  is  not  good  practice  to  put  into  a  building  SO-called 
fireproof  safes,  and  depend  upon  them  absolutely  for  protection. 
for  in  a  large  percentage,  which  runs  well  over  65  or  75,  it  has 
been  found  that  the  contents  of  these  nave  been  totally  destroyed 
in  large  fires.  The  statistics  on  the  subject  of  vaults  in  fires  show- 
that  the  besl  protection  is  afforded  by  the  brick  vault,  substantially 
constructed,  with  iron  doors  both  on  the  inside  and  outside  edge 
ot'  the  wall,  making  a  vestibule  between  them.     As  can  readily  be 


in;.  59. 

imagined,  the  holt  work  on  these  doors  must  he  of  the  h-'^t.  so  that 
when  they  are  dosed  they  are  practically  air-tight. 

SYSTEMS. 

Concbete.  In  the  choice  of  material  for  fireproofing  by  the 
reinforced  concrete  method,  such  materials  as  are  at  hand  must 
he  \\>ci}.  hut  these  should  he  either  crushed  stone,  slag  or  washed 
gravel.  In  using  the  latter,  care  must  he  taken  that  the  slag  is  of 
good  quality  and  that  the  gravel  is  thoroughly  washed,  screened 
and   free   from   loam.      It    is   stated  that  when   gravel    is   so   treated 


F1RE1  ROOI  I  No  1  8J 

that   owing-   to   the  variation   of   size  a  denser  and  m  <v  •  compact 
mass  can  be  obtained  than  by  other  means. 

Sand. — The  sand  to  be  used  in  this  form  <  f  construction  must 
be  free  from  loam  and  other  foreign  matter,  and  its  variation  in 
size  such  that  it  will  go  through  from  20  to  s'i  mesh  screens. 

Stone. —  If  broken  stone  is  used,  this  should  vary  in  size  from 
•"■  i  inch  to  1 \  ■_>  inches,  but  none  should  be  li  Ler  and  none  coarser. 
The  same  sizes  will  govern  crushed  slag.  If  gravel  is  used,  the 
size  of  the  stones  can  vary  from  whit  is  known  as  torpedo  sand 
to  1  j  •_.  inches.  It  is,  however,  better  to  screen  the  gravel,  getting 
the  stones  to  run  from  :;i  inch  to  I1-  inches,  as  for  crushed  stone, 
and.  mix  the  sand  afterward.  This  is  a  precaution  which  it  will 
be  well  to  insist  upon,  as  it  is  practically  impossible  to  get  gravel 
free  from  loam  and  in  screening  and  washing  this  is  eliminated, 
and  then  follows  the  same  course  as  for  crushed  stone  and  slag. 
The  matter  of  using  screenings,  as  the  fine  particles  of  crushed 
stone  are  called,  is  not  to  be  recommended,  as  the  greater  part  of 
this  is  usually  a  powder  which  will  not  make  as  strong  mortar  as 
clean,  sharp  torpedo  sand. 

Cement. —  In  the  choice  of  cement  for  the  work  it  is  safe  only 
to  use  the  very  best  Portland.  Not  too  much  stress  can  be  laid 
upon  this  point,  for  it  is  on  this  material,  its  proper  incorporation 
into  the  mass,  and  the  quality  of  it.  which  determines  the  strength 
of  the  whole.  It  is  a  matter  which  must  be  left  to  the  architect,  for 
lie  is  conversant  with  the  grades  and  quality  of  the  material. 
There  is  one  means  at  hand,  however,  which  will  be  worthy  of  note 
in  choosing  the  cement.  The  government  tests  on  the  material 
and  the  reputation  of  the  firm  making  the  material  will  be  the  best 
guide  in  most  cases. 

Concrete. — The  proportion  of  the  material  in  concrete  varies, 
but  for  ordinary  purposes  one  pari  of  cement,  two  and  one-half 
parts  of  torpedo  sand,  and  five  parts  of  crushed  stone  or  gravel 
will  be  the  standard.  For  beams  and  such  parts  of  the  work 
where  there  are  concentrated  loads,  the  proportion  would  be  one, 
two  and  four.  In  mixing  the  concrete,  if  it  i-  done  by  hand,  the 
method  given  here  is  probably  the  best.  Machine  or  "batch" 
mixtures  need  not  be  treated  liere,  as  the  concrete  construction 
companies  doing  this  work  have  then-  "batch'  mixers.  Of 
these  there  are  so  many  that  to  attempt  to  describe  them  would 
necessitate  a  special  treatise  in  itself. 

By  the  hand  mixing  process   which  in  most  instances,  .it  pres 
(tit.  is  the  one  used,  the  sand  should  be  spread  two  inches  thick 
on  a  tight  floor;  the  cement  is  then  spread  evenlj  over  this.    Th 
are  then  thoroughly  mixed  until  a  uniform  color  is  obtained.    The 


L82 


FIREPROOFING 


water  is  then  added  and  the  mixing  continued  until  a  good,  plastic 
mortar  i>  formed.  This  mortar  is  then  spread  about  two  inches 
thick,  covered  with  crushed  stone  and  mixed  forward  and  back 
until  all  voids  of  --tone  are  filled  and  the  face  of  each  stone  is 
thoroughly  covered  with  mortar.  The  concrete  is  then  put  into 
place  and  rammed  until  water  appears  on  the  surface.  Extreme 
care  must  he  taken  in  putting  the  water  into  the  mixture  that  it 
has  not  sufficient  forced  to  wash  out  the  cement.  Slushing  water 
with  a  pail  should  not  be  permitted.  Ali  watei  should  be  sprinkled 
on  the  mass. 

Suspended  Work. — This  is  of  two  kinds — that  without  the 
use  of  steel  beams  and  that  which  has  such  structural  shapes.  The 
first   method  is  shown  in   Fig.  00,  where  the  tloor  runs  from  wall 


=5=3? 


FIG.  60. 

to  wall,  and  the  second  as  shown  in  Fig.  01.  Ordinarily  in  rein- 
forced concrete  work  all  beams  are  also  of  the  reinforced  type.  As 
stated  elsewhere,  the  systems  will  not  he  described  except  as  is 
necessary  to  illustrate  the  different  methods.  The  entire  design 
of  Midi  a  tloor,  so  far  as  its  thickness  and  general  construction  is 
concerned,  including  the  reinforcements,  depends  solely  upon  the 
loads  to  he  sustained.     For  hospitals  the  following  table  (Fig.  62) 


FIG.  61. 


will  give  such  load-,  which  lor  the  purpose  of  hospital  construction 
are  sufficient.  In  exceptional  cases  where  there  are  concentrated 
loads,  such  as  water  tanks  in  pent  houses,  special  and  exact  cal- 
culations will  he  accessary.    All  loads  given  are  "live"  loads,  and 


ETREFROOFING 

the  weight  of  material  used  in  the  construction  of  floors  must  be 
added  to  these: 

Live  loads  for  floors 80  Los. 

*Live  loads  for  ceiling 35  Lbs. 

Live  loads  for  roof  50  Lbs. 

Live  loads  for  stairs sn  11,s- 

FIG.  62. 

BEAMS.-Beams,  as  mentioned,  can  be  of  two  kinds-struc 
tnral  shapes  or  of  reinforced  concrete.    Fig.  61  shows  the  former 
acd  Pig   81  shows  the  latter  form  of  construction.     The  use  ol 
structural  shapes  is  usually  attended  by  fireproofmg  ol  tile,  but 

as  shown  in  the  figures,  this  is  unnecessary,  as  ,t   can   lone 

wholly  in  concrete.  Care  must  he  taken,  however,  to  reinforce  Jie 
,ower- edges,  as  shown  at  "A,"  as  it  is  here  that  the  protection 
usually  peels  off.     With  a  reinforcement   as   shown   this   ttould 


FIG.  63. 

Saddle. 

•ii        tv  ri.o  ll'it  hroe  floor,  where  all  sup- 
practically  be  impossible.     In  the  Hat  typ<  , 

'    -,iw   n«  iii  Fie   1    such  beams  are  only  necessar)   ovei 
ports  are  walls,  as  in  r  Lg.  j., 

°Pe"cXEB1Ko.-In  sns led  floors  ,  should  be  taken  that 

all  centerings-i.  c,  supports  I'm-  the  work  during  - structioi 

ao  seurelv  built  of     urfaced   material,  straight,  smooth    and 
!  WP  -v,l  and  of  such  character  that  the  ii -  are  held  in 

£ l^Xe  terete  has  set     0 ^^^Z 

less  than  two  weeks,  and  three  weeks  would  be  better.    When  the 

are  removed  this  should  1 arefmly  done  to  prevent  deflections 

and  marring:  of  the  wort  , 

Test     All  fl s  should  be  tested  with  uniformly  £>£*atod 

loads  of  not  less  than  twice  the  live  1 1  .■all,.!-.     II  thej  de- 

fleet  under  those  I. s,  when  the  latter  are  wholly  removed  (aftet 

sustain   special   loads  as  mentioned. 


184 


kirk]  roofixo 


at  least  twenty-four  hours)  the  floors  should  assume  their  former 
position  without  showing  deflection  under  micrometer  tests. 

Iron.  All  iron  should  be  protected  from  fire  by  at  least  one 
inch  of  concrete  and  in  beams  this  should  be  at  least  LVj  inches. 
There  should  be  QO  rust  scales  on  the  iron  when  put  into  the  build- 
in-,  but  a  slighi  film  of  red  rusl  is  not  objectionable.  Xo  bars 
in  reinforced  concrete  should  be  painted,  as  this  prevents  the  ad- 
hesion of  the  concrete  to  the  iron,  the  bond  being  imperfect. 

Pipe  Slots.  All  slots  for  pipes  should  be  formed  by  sleeves 
of  galvanized  iron  or  wooden  blocks,  so  as  to  prevent  the  necessity 
of  breaking  such  holes  through  for  pipes  after  the  floors  are  com- 
plete, [f  holes  must  be  put  in  after  the  concrete  is  set.  they  should 
be  carefully  drilled. 

Roof.  The  roof  should  be  finished  with  a  coat  at  least  i.  inch 
thick,  as  is  done  on  floors,  and  given  the  proper  slope.  The  method 
of  covering  this  will  be  described  in  the  chapter  on  roofing  (Fig. 
66). 


Bm3§k 


FIG.   (>4. 
Reinforced  concrete  skylighl 

rl  oo  often  the  matter  oJ  proper  drain  of  roofs  is  not  seriously 
considered,  this  being  dismissed  with  but  little  thought  for  the 
besl  methods.  At  .ill  points  when  the  slope  is  intercepted  by 
vertical  obstructions,  such  ;is  skylights  and  chimneys,  saddles 
should  he  built.  The  filling  for  these  can  he  oi  cinders,  bu1  the  top 
must  have  a  heavy  finishing  coat.  Fig.  (»:;  ^h.,ws  such  a  saddle. 
The  skylights  above  the  ceiling  line  can  he  built  of  concrete,  that 


FIREPROOFING 


185 


portion  above  the  roof  being  of  reinforced  type.  Fig.  61  shows  a 
simple  form  of  such  a  skylight. 

Skylights  will  be  fully  treated  elsewhere. 

Stairs. — Stairs  of  reinforced  concrete  need  no  special  men- 
tion. 

The  illustration  (Fig.  65)  given  here  will  be  sufficient  to  show 
how  one  of  the  many  forms  are  built.  Care  should  be  exercised 
to  have  proper  lugs  built  in.  to  which  the  guards  or  railings  can  be 
fastened.  Some  of  these  stairs  are  built  with  stringers  of  rein- 
forced concrete.  The  risers  and  treads  of  such  stairs  can  be  fin- 
ished in  flake  mosaic,  or  the  treads  can  be  equipped  with  patent 
safety  treads.  Marble  is  not  recommended  for  treads,  but  one  of 
the  varieties  of  slate  is  very  satisfactory. 

CEMENT  WORK  NOT  SUSPENDED. 

Floors. — Before  leaving  tic  subject  of  concrete  fireproofing 


FIG.  65. 

Stair  of  concrete. 


w*%va®!%8 


the  matter  of  concrete  doors  for  bases,  areas,  etc.,  will  be  men- 
tioned. They  do  not  ordinarily  come  undei  the  bead  of  fireproof 
ing,  but  in  all  such  work,  of  whatever  system,  there  is  some  con- 
crete used,  and  the  entire  concrete  work  is  ordinarily  done  under 
one  contract.  The  subject  is  one  with  which  all  architects  are 
familiar  and  needs  no  separate  chapter.  The  ground  upon  which 
the  floors  are  to  be  laid  should  be  camped  solidly,  and  in  all  cases 
covered  with  cinders  al  least  6  inches  thick;  these  should  be  also 
tamped  wet  to  make  a  firm  surface  ready  for  the  concrete.  Upon 
this    base   is    laid    the   concrete   at    leasl    •'>    inches    thick.      The    pro 


is<i  FIREPROOFING 

portions  of  tliis  and  the  manner  of  putting  it  down  being  the  same 
as  for  suspended  work. 

Upon  this  concrete  is  put  the  wearing  surface,  which  should 
lie  •"■  |  inch  thick,  made  of  one  pari  of  cement  and  one  part  of  sand. 
This  should  be  leveled  off  with  proper  slopes  to  all  drains  and 
then  trowelled  down  within  two  hours.  The  latter  process  must 
be  done  carefully,  as  too  much  working  draws  the  cement  to  the 
surface  and  makes  a  brittle  floor,  which  cracks  and  crumbles.  The 
important  point,  however,  in  laying  the  basement  floors  is  that 
they  be  made  thoroughly  water  and  gas  proof.  This  can  be  done 
in  several  ways,  but  only  two  such  methods  are  given  here.  The 
first  has  the  decided  advantage  of  being  both  effective  and  econom- 
ical and  needs  no  special  care  other  than  is  usually  employed  m 
mixing  concrete.  The  second  applies  more  directly  to  localities 
where  there  is  tide  water.  A  combination  of  the  two  methods  can 
also  be  used.  The  first  method  has  been  described  under  Masonry 
in  connection  with  damp-proofing  of  walls.  It  consists  of  mixing- 
about  2  per  cent,  of  specially  prepared  compounds  in  powder  form 
with  the  dry  cement  and  then  proceeding  as  ordinarily  described 
lor  the  work.  The  second  method  has  also  been  described  under 
Masonry  and,  as  stated,  applies  more  directly  to  localities  where 
tide  water  prevails.  The  latter  method  is  shown  in  Fig.  '20,  which 
also  shows  the  construction  of  the  floor  as  mentioned  above. 


ami 


FIG.   <>(>. 

After  the  rough  concrete  or  base  is  laid  over  the  cinders,  the 
damp-proofing  mentioned  under  Masonry  must  be  laid  flat,  as 
shown  in  Fig.  21,  and  over  this  key,  as  well  as  over  the  entire 
floor,  two  layers  of  tarred  felt  should  be  laid,  with  special  cements 
applied  as  interlay  between  these,  and  also  on  top  and  bottom  as 
well.  Tar  products  with  cement  construction  are  not  impervious 
either  to  water  or  gas,  and  both  of  these  must  be  most  rigidly  ex- 
cluded. 

Alter  the  floors  are  dry,  preferably  just  previous  to  occupancy 
of  the  building,  they  should  he  filled  with  a  cement  filler,  and 
given  a  heavy  coating  of  cement  floor  paint.  This  makes  floors 
so  treated  impervious  to  either  oil  or  water,  and  above  all  pre- 
vents disintegration  of  the  cement  and  dust  produced  by  friction 
of  shoe  soles,  which  has  been  a  very  serious  objection  heretofore. 

Sidewalks.  It  is  not  necessary  to  dwell  at  any  length  upon 
.he  subjeel  of  sidewalks,  hut  the  same  care  should  be  exercised 
in   this  as   in  the   remainder  of  the   work.      Cinders   should  alwavs 


FIKEPR00FING 


187 


be  used  as  a  base.  In  making  driv<  ways,  they  should  be  built  witii 
crushed  granite,  about  one  inch  cube  instead  of  u&ing  crushed 
stone.  The  surface  should  be  one  inch  thick  instead  of  three- 
quarters  inch,  as  for  other  work,  and  should  be  deeply  corrugated 
to  prevent  slipping,  with  the  corrugations  made  so  as  to  drain. 

HOLLOW    TILE. 

In  this  form  of  construction,  where  the  use  of  structural  iron 
is  necessary,  there  will  he  no  attempt  made  at  calcinations  of  the 
size  of  such  shapes,  as  this  i<  purely  an  engineering  problem. 
Mention  is  made  here,  however,  of  f!iis  point,  in  order  t<-  show  that 
no  exact  data  can  be  given  offhand  without  concise  detail  as  to 
length  of  spans,  loads  and  method  of  applying  the  tile.  The  illus- 
trations show  these  methods  without  reference  to  the  engineering 
calculations  mentioned  (Figs.  67,  68,  (>!',  89). 

rj:::j^:::r.::::::--:;rr.y,,::^,,.:,^-j'..r...'s--r',r.-,:.::~ 


FIG.  67. 

Flat  arch. 


FIG.   68. 


1/ ' 

o 

ODD 

aee= 

& 

■-N 

M 

FIG.  69. 

After  the  structural  iron  is  placed  in  the  building  it  is  encased 
in  fire-clay  tile,  except  such  portions  which  in  the  construction  of 
the  building  are  encased  in  brick  or  concrete.  The  shapes,  sizes 
and  different  usages  to  which,  this  fire-clay  is  put  in  the  construc- 
tion are  fully  illustrated. 

It  is  necessary  that  in  placing  tile,  other  iron  than  the  struc- 
tural iron  be  used.  These  consisl  of  T  and  I.  irons,  shaped  as  their 
names  imply,  which  are  put  into  vault  tops,  Lintels  over  doors  in 
interior  partitions,  and  in  ceiling  and  roof  construction,  as  in 
Fig.  66. 


188 


FIREPROOFING 


Tile. — This  is  a  fire-clay  materia]  which  should  be  hard  burned 
and  free  from  defects  for  use  in  fireproof  buildings.  From  this 
are  built  the  floors,  ceilings,  roofs,  partitions,  furring,  backing  of 
walls  and  the  encasing  of  all  steel  and  iron  work  and  pipe-. 

The  tile  is  pui  Into  floors  in  arches,  cither  flai  or  segmental, 
as  shown  in  Fig's.  67  to  71.     Partitions  are  put  directly  on  these 


FTG.    70. 
Segmental  arch. 

floor  arches,  as  shown  in  Figs.  57  and  58,  and  vary  in  construction 
with  the  type  and  thickness  of  tile  used.  They  should  be  made 
straight  and  plumb,  as  the  plastering  goes  directly  on  them.  The 
blocks  should  be  scratched  before  being  burned  to  admit  the  plas- 
ter and  make  a  good  bond. 


fig.  71. 

Columns^-  -Columns  are  usually  fireproofed  with  special  tile, 
in  some  instances  provided  with  slots  to  receive  pipes  where  these 
come  at  such  points,  as  shown  in  Figs.  72  and  7.">.  The  tile  should 
be  set  with  an  air  space  between  fireproofing  and  metal.  Each 
tile  should  also  be  secured  in  place  and  to  each  other  by  means  of 
keys  and  to  the  column  by  heavy  copper  wire.    Figs.  72  to  78  show 


in,.  <_. 

types  ot*  fireproofed  columns  and  the  manner  in  which  they  are 
protected  as  docribed.  Fig.  79  and  Fig.  80  show  the  reinforced 
concrete  columns  with  tile  on  the  exterior. 

Roof.— In  the  construction  of  the  roof  the  fiat  arch  is  used, 
and   where  saddles  are   required,  as  described   under  reinforced 


I'-IREJ  K<  0I1NG 


189 


concrete,  they  are  "furred  up"  with  cinder  concrete  and  finished 
with  the  remainder  of  the  roof.  All  tile  above  the  roof,  or  wher 
ever  it  is  exposed  to  the  weather,  should  be  vitrified  so  as  to  be 

waterproof. 

Skew  Backs,— As  shown  in  the  illustrations,  Fig.  70  and  Big. 


Dg.l[5pg 


FIG.    16. 


71,  the  skew  hacks  or  spring  of  the  arches  should  he  carefully  set 
and  rest  squarelv  on  the  flanges  of  the  beams  and  make  connection 
with  the  fireproofing  under  the  beams;    such  shapes  must  neces- 


Dl 

Q 

D 


opq 


i 


r 


Q 

0 


0 


p 

niiopqi: 


FIG.  74. 

sarily  be  made  as  will  do  this  in  all  eases.    The  keys  of  the  arches 

must  also  fit  tightly. 

Slots.— Slots  in  column  fireproofing  should  he  molded  so  as 


to  prevent  cutting  in   these  tile.     Dies  arc  usually  made  for  this 
purpose  and  the  tile  made  from  these.    See  Pigs.  72  and  1Z. 

Setting.— It  is  important  that  all  of  the  tile  work  ;it  closely; 


190 


F1RF1  ROOFING 


thai  is.  extend  close  to  walls  and  ceiling  and  lit  closely  around  all 
pipes  and  other  openings;  thai  no  mortar  joints  should  exceed 
one-half  inch  in  thickness;  that  the  tile  be  laid  to  break  alternately 

in  all  ciim's;  that  all  joints  be  slushed  full,  except  the  hook  tile 
where  joints  are  smooth  and  the  surface  even. 

Mortar. — The  mortar  for  tile  fireproofing   work   should   be 
good  lime  mortal-  tempered  with  cement.     This  tempering  should 


FIG.  76. 

be  done  on  the  scaffold  when  the  tile  is  laid  and  not  before,  or  in 
quantities  as  the  cement  sets  quickly, 

Deafening. — Sound-proofing  is  done  in  the  manner  described 
in  reinforced  concrete,  ami  it  is  well  to  again  call  attention  to  the 
protection  of  pipes  when  cinder  concrete  i.>  used  lor  this  portion 


PIG.    11. 

of  the  work.    Sleepers  are  put  in  for  floors  where  they  arc  of  wood, 
as  shown  in  Pig.  67. 

oil  I  EB    M  Kl  Molts. 

AlS  shown  in  Figs.  81,  82,  83,  84,  a  combination  of  hollow  tile 
and  reinforced  concrete  is  used.  There  are  several  methods  em- 
ployed in  this  class  of  construction,  hut  a  general  discussion  will 
fully  explain  them,  as  they  arc  al!  of  the  same  character.  The 
system  shown  in  Pig.  si  has  many  admirable  features  The  use  of 
the  tile  t»>  fireproof  the  concrete  is  unique,  inasmuch  as  the  former 
is  fireproof.  The  argument  advanced  in  favor  of  this  form  of 
construction  is  that  in  severe  fires  concrete  is  liable  to  disintegra- 
tion, ami  that  the  tile  protects  the  concrete,  and  even  if  the  former 


FIRF.PROOJ  I  N(. 


191 


is  badly  damaged  it  can  be  removed,  Leaving  the  strength  of  the 
floor  unimpaired. 

The  fire-resisting  qualities  of  concrete  have  been  subjects  of 
much  dispute.     Theoretically,  the  above  may  be  true,  as  concrete, 


fig.  78. 
being  a  hydrated  compound,  should  disintegrate  with  the  evapora- 
tion of  the  water  of  this  hydration  by  the  heat.    Practically  such 
is  not  the  case,  for  it  would  require  extremely  high  temperature 
to  draw  off  the  water  of  hydration,  inasmuch  as  concrete   is  a 


FIG.   79. 

poor  conductor.  In  actual  tests  by  experts  and  municipalities,  and 
in  many  conflagrations,  the  theory  has  been  absolutely  contro- 
verted, for  concrete  has  withstood  the  severesl  test  in  all  of  these 
cases. 


fig.  80. 
However,  as  the  tile  is  not  meant  to  add  strength,  but  merely 
to  protect  the  structural  parts,  H  is  mentioned  here  as  a  method. 
In  Figs.  79  and  80  columns  of  this  construction  are  shown.     So 


192 


FJREPROOI  [NG 


far  as  cosl  of  construction  is  concerned,  there  can  be  no  material 
difference  between  this  form  and  the  simple  reinforced  concrete. 
The  tile  being  beneath  the  concrete  would  necessitate  mueli  simpler 
and  less  expensive  centerings,  but  the  additional  cosl  of  tile  would 
offset  tins. 


FIG.   81. 

In  Fig.  85  is  shown  a  form  of  construction  which  is  admirable 

and  is  especially  mentioned  here,  since  it  embodies  the  first  prin- 
ciples of  the  joisl  construction.     It  is  extremely  simple  and  rapid 


FIG.  82. 

in  its  application  and  is  doubtless  one  of  the  best  forms  that  can 
be  used  for  fireproof  floor  construction.  It  provides  a  flat  arch 
with  that  portion  which  docs  not  directly  contribute  to  the 
strength,  except  in  compression  in  a  Lateral  direction,  of  material 


l-'lliKI'ROOFlNO 


i!'.; 


which  makes  floors  from  30  to  40  per  cenj  Lighter  than  systems 
of  all  reinforced  concrete  and  still  retains  all  <»1*  the  advantages  of 
the  latter  as  to  strength  and  economy. 

The  reinforcement  is  placed  in  the  concrete  joists,  as  shown, 
with  a  lateral  reinforcement  over  the  top. 


fig.  83. 

The  system  illustrated  in  Figs.  82,  83,  84  is  for  Ion-  span,  Hat 
construction.  The  three  illustrations  show  the  construction  to  an 
end  wall,  a  bearing  wall  and  over  structural  shape,  and  are  the 
same  in  this  regard  as  the  all-concrete  floor.    It  is  the  reinforced 


FIG.   84. 

pattern  and  can  he  erected  wholly  without  structural  iron.  It  is 
from  30  to  m  per  cent  Lighter  than  the  reinforced  concrete  for  the 
same  strength,  and  has  the  advantage  of  being  practically  sound- 
proof. This  system  is  formed  of  large  steel  wires  transversely 
interwoven,  with  still  Larger  wires  placed  4  inches  apart.     These 


VM 


I  [REPROOFING 


Inst   niii  from  bearing  to  bearing  in  unbroken  lengths  along  the 
line  of  natural  tension. 

Skylights.  -What  has  been  said  under  concrete  regarding 
skylights  refers  also  to  these  in  all  tile  construction,  or  in  a  com- 
bination of  these  methods.  Fig.  88  shows  a  skylight  built  of  tile 
on  a  reinforced  concrete  roof. 


FIG.   85. 

Stairs.— Stairs  of  concrete  have  been  fully  described  and 
illustrated.  Those  of  other  fireproof  material  can  be  built  in  sev- 
eral ways.  In  Fig.  S(j  is  shown  such  a  stairway,  built  entirely  of 
hollow  tile.  The  risers  and  treads  of  these  can  be  finished  with 
marble,  some  variety  of  slate  or  in  plastic  material  like  cement 
with  safety  treads  set  into  the  material,  or  they  can  be  built  of 
terra  cotta  tile  completely. 

Fireproof  stairs  are  built  as  shown  in  Fig.  87,  entirely  of  iron, 


0 


Pi 
lU? 


0. 


o^ 


0; 


0 


am. 


mm 


.  "=*.  Q  :£?•((■  <=i  '■<=? tt(^.^^(.&&& 


TOO 


DO 


W/////W7777777X///////W/////A 


FIG.  86. 


the  stringers,  risers  and  trends  being  of  this  material.    The  trends 
«  n  these  are  often  made  of  marble  or  stone. 

Handrails  for  stairs  should  be  placed  on  both  sides.  The  pat- 
tern of  these  depends  wholly  upon  the  general  design  of  the  entire 
work.  If  stnirs  are  built  around  the  elevator  sluft  in  their  own 
brick  or  tile  enclosures  a  simple  handrail  securely  fastened  to*  the 
wall,  or  brackets  on  one  side  and  fastened  in  the'  same  manner  to 
the  iron  enclosure  of  the  shaft  on  the  other,  is  sufficient.     These 


FIBEPllOOFING 


1!).") 


are  matters  of  detail,  however,  with  which  all  architects  arc  ta 
miliar. 

Under  this  heading  also  must  be  placed  the  metal-clad  trim, 
doors  and  other  interior  wood  work  mentioned  in  the  chapter  on 
Carpenter  Work.  Pigs.  38,  41,  52,  53,  54  show  this  form  of  fire- 
resisting  woodwork. 

The  all-metal  form  for  the  interior  trim  of  buildings  is  ad- 
mirable in  many  ways,  but  its  disadvantages  lie  in  the  fact  that  it 


fig.  8/. 
is  both  expensive  and  heavy.     It  is  made  of  bronze  or  other  heavy 
metal,  so  as  to  prevent  denting.    As  will  be  evident,  doors  of  these 
materials,  while  they  would  have  the  fireproof  qualities,  would  be 
too  cumbersome  for  ordinary  purposes. 

Fireproof  Windows. — Little  need  be  said  regarding  fireproof 
windows,  as  these  wore  fully  explained  in  the  chapter  ou  Car- 
pentry (Figs.  50  and  51).  Mention  is  made,  however,  of  the  all- 
metal  form  of  frame  and  sash.  These  have  many  advantages  be 
sides  their  fireproof  qualifications,  theii  durability  and  the  Pad 
that  they  are  not  subject  to  change  it:  form  or  shape  due  to  weather 
conditions.  Expansion  and  contraction  of  the  metal  is  amply 
provided  for  in  the  better  forms  el'  these,  so  thai  they  are  at  all 
times  easily  operated. 

Wire  Glass. —  Wire  giass  as  a  lire  retardenl   is  too  weli   fee 
ognized  to  need  special  at  lent  ion.     This  material  comes  in   many 
forms — the  translucent  maze  ami  chipped  uia>>,  rough  wire  glass 


19G 


I  [REPROOFING 


for  skylights  and  the  polished  plate  wire  glass  for  interior  parti- 
tions. This  glass  lias  the  added  advantage  of  being  less  liable  to 
breakage  than  the  ordinary  plate  or  window  glass,  the  wire  acting 
as  a  reinforcement.  In  doors  where  glass  is  used  this  would  be 
of  meat  value. 

Fireproof  Paints. — The  subject  of  fireproof  paints  is  one 
which,  in  hospitals,  need  not' be  seriously  considered,  except  in 
instances  where  it  is  desirable  to  use  them,  as,  for  example,  in 
painting  shelving  in  store  rooms. 

Lockers. — Lockers  have  been  fully  treated  in  another  chapter. 


l^vyw^vv^^^^. 


iki.  88. 

hut  attention  is  again  directed  to  the  fact  that  these  should  be  ab- 
solutely fireproof.     Figs.  55  and  56  show  such  lockers. 

rrp.FPP.ooF  wood. 

Fireproof  wood,  as  its  name  implies,  is  wood  treated  in  such 
a  manner  that  it  will  not  burn.  It  is  tire  resisting,  or  slow  bnrn- 
ning,  rather  than  fireproof.  There  are  several  processes  by  which 
this  el't'ect  is  produced,  all  of  which  are  patented,  and  all  of  which 
are  widely  different  in  character.  In  general,  the  method  con- 
sists of  impregnating  the  wood  fiber  with  certain  chemicals.  The 
wood  must  be  kiln  dried  for  several  weeks  after  this  impregnat- 
ing, so  that  the  wood  is  "bone  dry."'  The  treatment  in  no  way 
affects  the  color  of  the  wood,  except  to  make  it  somewhat  richer  in 


FIREPROOFING 


19' 


tone,  and  in  no  way  Lmpairs  it-  strength  or  its  working  quality. 
The  industry  is  evidently   in   its  infancy.     The  government   uses 


this  wood  in  battleships  which  would  indicate  thai  it  Las  merits. 

Fireproof  floors  of  wood,  with  an  air  space  under  them,  make 
excellent  fire  retardents. 


CHAP'lER  XIV. 

PLUMBING. 

Plumbing  to  the  majority -of  people  simply  means  the  installa- 
tion of  certain  fixtures  in  given  spaces,  arranged  conveniently  for 
various  purposes.  This  primarily  may  be  the  ease.  Imt  the  ob- 
jects to  be  attained  by  plumbing,  and  the  means  of  obtaining 
them,  are  much  more  complicated  and  of  vastly  more  importance. 
Strictly  speaking  the  fixtures  are  secondary,  and  the  demand  for 
their  being  placed  conveniently  has  given  rise  to  the  essentials 
of  sanitary  plumbing. 

\)\\  Azel  Ames  says:  "It  goes  without  saying  that  pri- 
marily the  object  of  plumbing  laws  in  states,  and  of  ordinances 
of  like  character  in  municipalities,  is  to  secure  for  the  public 
safety  from  unhealthy  influences  known  to  reside  in  sewage  and 
its  gases.  It  is.  however,  a  fact  well  known  to  those  familiar  with 
these  Laws  and  their  genesis,  and  with  the  advanced  knowledge 
of  recent  years  in  sanitary  science,  including  physics,  bacteriology 
and  pathology,  that  there  is  scarcely  a  state  or  ;i  community  in 
which  the  so-called  sanitary  laws,  and  more  especially  the  laws 
and  ordinances  relating  to  plumbing  and  sanitary  construction,  lit 
the  fact-  or  accomplish  what  they  are  ostensibly  designed  to  do. 

A-  ;i  matter  of  fact,  in  a  very  large  percentage  oi  cases  they 
defeat  their  primary  object,  and  are  positively  unsanitary  in  their 
results,  while  their  enforcement  by  authority  is  an  outrage  upon 
the  citizen,  a  travesty  upon  present  sanitary  knowledge.  This  is 
due,  as  has  been  suggested,  in  no  small  number  of  cases  to  the 
fact  that  most  of  the  now  existing  sanitary  laws  ami  ordinances 
were  framed  and  adopted  by  those  having  lmt  little  sanitary 
knowledge,  and  since  the  time  of  their  adoption  have  not  been 
changed,  amended  and  improved  to  keep  pace  with  the  rapid  and 
positive  advances  in  sanitation.  The  existing  requirements  of 
construction  have  been  copied  generally  from  0m1  city  and  town 
by  the  other,  with  the  result  that  the  above  named  condition  is 
\ -» -r\   general." 

It  will  be  -cm  from  this  that  it  is  not  safe  or  expedient  to 
rely  upon  state  or  municipal  laws  for  the  essentials  of  good 
plumbing.  This  is  particularly  true  of  plumbing  in  hospitals, 
where  it  is  imperative  to  have  only  the  besl  and  mosl  modern.     It 


PLUMBING  199 

is  not  the  object  of  the  authors,  nor  within  the  province  of  such 
a  volume  as  this,  to  go  into  the  minute  details  necessary  to  obtain 
the  best  results.  The  architect's  specification  should  fully  cover 
all  of  these  points,  and  his  knowledge  of  sanitary  science  should 
be  sufficient  to  see  that  they  are  carried  out.  Plumbing,  however, 
is  not  limited  to  sanitation,  although  its  objecl  is  to  attain  this 
end  and  eventually  revolves  about  this  pivotal  point. 

It  is  only  within  recent  years  that  hath  and  toilet  rooms  have 
been  made  commodious,  with  proper  lighting  and  ventilation. 
The  old  method  of  inclosing  all  fixtures,  such  as  lavatories,  sinks, 
tubs  and  closets,  with  wood,  and  putting  then,  in  the  darkesl  and 
poorest  ventilated  spaces  has  been  entirely  superseded  by  the 
modern  bathroom  and  toilet  room,  with  an  abundance  of  sunlight 
and  ventilation.  Moreover,  the  fixtures  themselves  are  now  sei 
free  from  walls  and  are  so  made  that  every  part  of  them  is  ex- 
posed and  can  be  kept  clean.  Instead  of  the  old  iron  closet  with 
its  wooden  seat  and  surrounding  box,  wo  have  the  closet  made  of 
vitreous  ware.  Sinks,  lavatories  and  hoppers  are  now  made  of 
enameled  iron  and  vitreous  ware  or  porcelain  wire,  which  are 
absolutely  non-absorbent. 

Drainage  systems  are  not  the  result  of  guesswork,  but  are 
now  proportioned  in  size  by  exact  computation  of  requirements. 
Ventilation  of  these  systems  is  calculated  as  exactly  as  it  i>  for 
rooms.  Supply  pipes  for  water  are  not  installed  in  the  hap- 
hazard fashion  of  former  years,  but  each  pipe  is  designed  for  the 
amount  of  water  it  is  to  supply.  Water  supply  itself  has  under- 
gone pronounced  changes,  as  only  the  purest  water  is  now  \\>r<\, 
and  if  not  directly  obtainable,  systems  of  filtration  are  installed 
and  sterilization  and  distillation  plants  are  put   in. 

Piping  has  undergone  a  radical  change  also,  [nstead  of  light 
piping  of  lead  and  iron,  we  now  have  heav\  lead  pipe,  brass  pipe, 
white  metal  piping  and  galvanized  seamless  iron  tubing  and  pipe. 
The  connections  and  fittings  for  these  have  been  designed  with  n 
view  of  decreasing  friction,  o!  making  any  desired  change  in  di- 
rection gradual. 

All  of  these  have  directly  contributed  to  the  general  improve 
ment  so  that  now  a  modern  system  of  plumbing  and  iti    installa- 
tion has  become  an  exact  scientific  reality. 

The  general  conditions  necessary  for  the  installation  of  such 
a  system  are  not  in  the  leasl  complicated,  a--  will  be  seen.  The 
special  requirements  of  such  systems  are.  however,  a  serious  prob- 
lem forthe  architect  and  sanitary  engineer.  A  water  supply  sys 
tern  in  a  hospital  may  be  simple  and  still  be  of  such  nature  as  to 
make  its  installation  the  most  difficult. 


200  PLUMBING. 

System  and  installation  arc  often  widely  divergent.  At  first 
glance  the  supplying-  of  fixtures  may  appear  without  the  least 
semblance  of  intricate  calculation,  bnt  the  running'  of  supplies 
for  hot  and  cold  water,  both  filtered  and  distilled,  with  all  of  the 
attendanl  apparatus,  and  the  great  distances  between  fixtures  in 
differenl  pails  of  the  hospital,  are  serious  considerations. 

The  primary  requirements,  however,  in  ail  hospitals  are  suf- 
ficient water  at  all  times  for  all  purposes;  fixtures  of  the  open 
type,  cither  in  enameled  ware,  porcelain  or  vitreous  ware;  waste 
pipes  calculated  as  to  size  so  that  they  wiil  he  self -cleaning,  but 
not  so  small  as  to  not  fulfill  all  requirement^;  ventilation  of  rooms, 
fixtures  and  the  system;  good  joints  in  good  quality  pipes,  and 
pipes  that  will  not  corrode;  a  system  that  is  water-tight,  gas- 
tight,  ami  which  is  so  installed  that  it  will  drain  perfectly  at  all 
times,  and  one  which  is  securely  installed;  one  which  will  work 
perfectly  so  that  there  will  be  no  interference  of  one  portion  with 
.■mother;  which  is  noiseless  in  operation  and  which  is  accessible 
in  all  its  parts  throughout. 

DRAINAGE  SYSTEMS. 

The  drainage  systems  in  hospitals  include  the  house  sewer, 
house  drain,  soil,  wTaste  and  vent  stacks,  branch  fixture  connec- 
tions and  fixtures  and  the  subsoil  drainage.  The  house  system  is 
that  portion  of  the  system  which  connects  the  house  drain  with  the 
-tree)  sewer,  or  to  such  other  means  as  is  provided  for  the  proper 

disposal   of  sewage. 

Tile  Seweks. — While  tile  pipe  is  not  the  best  for  the  house 
sewer,  it  is  sometimes  necessary  to  use  this,  owing  to  local  re- 
strictions, and  also  to  the  fact  that  the  distance  from  the  building 
to  the  main  sewer  or  other  point  of  sewage  disposal  is  so  great 
as  to  preclude  the  possibility  of  using  iron  pipe. 

When  tile  pipe  is  used  it  should  he  of  the  salt  glazed  variety 
with  a  perfeel  surface.  The  huh  end  and  the  spigot  end  must  be 
unglazed  to  permit  the  cement  to  adhere  to  make  a  perfect  joint. 

The  laying  of  tile  pipe  can  he  done  in  several  ways.  In  all 
of  these  methods  a  trench  is  dug,  which  is  properly  graded,  so 
that  when  the  sewer  is  laid  it  permits  an  easy  How  of  the  contents 
of  the  sewer  to  the  point  of  discharge.  The  tile  is  laid  on  the  bot- 
imii  of  this  trench  and  blocked  to  make  an  even  slope.  The  joints 
are  cemented  and  these  should  then  he  protected  by  tilling  in  over 
them  carefully  before  the  trench  is  closed,  so  as  to  prevent  break- 
ing of  the  joints.  The  earth  under  each  hub  should  be  removed 
when  the  pipe  is  laid,  thus  giving  a  bearing  for  the  full  length  of 
the  pipe,  which  is  better  than  blocking.    The  method  of  making  a 


PLUMBIXO. 


201 


concrete  foundation  for  the  sewer  is  scientifically  the  best,  but 
the  cost  of  doing  this  often  exceeds  the  cost  of  making  the  entire 
sewer  in  iron,  and  is  therefore  not  advocated  when  tile  sewers  are 
used. 

In  laying  tile  sewer  it  is  imperative  thai  any  imperfections, 
such  as  warps  or  heads,  should  be  laid  on  the  side,  so  as  to  form 
no  pockets.  Tile  sewers  are  sometimes  laid  on  a  plank  founda- 
tion. In  this  method,  the  spigot  ends  must  be  blocked  into  the 
hubs.  This  is  a  good  method  where  it  is  necessary  to  Lay  the  pipe 
quickly.  If  unglazed  hubs  and  spigots  are  not  obtainable,  the 
joints  should  be  calked  with  oakum  and  filled  with  either  cement 
or  asphalt,  preferably  the  latter. 

Tile  sewers  should  never  be  used  where  they  cannot  be  laid 
below  the  frost  line,  or  when  they  run  near  a  well  or  other  source 
of  water  supply. 

Tile  sewers  in  general  are  not  recommended,  as  the  joints 
cannot  be  made  tight,  and  also  because  they  are  subject  to  injury 
in  many  ways.  House  drains  in  hospitals  should  never  be  of  tile 
for  the  reason  given. 

Iron  Sewers. — Iron  sewers  possess  none  of  the  disadvantages 
of  tile  sewers.  They  are  not  subject  to  breakage  at  the  joints 
nor  in  the  pipe  as  are  tile,  and  inasmuch  as  all  joints  are  both 
water  and- gas  tight,  they  can  be  ran  in  proximity  to  water  supply 
without  deleterious  effects.  Frost  will  not  injure  them  as.readily 
as  tile  sewer,  and  settlement  in  the  pipe  will  not  break  the  joints; 
the  inner  surfaces  at  joints  are  not  subject  to  obstructions.  Iron 
sewers  are  made  standard  and  extra  heavy,  bul  the  former  should 
not  be  used,  owing  to  the  danger  of  breakage  in  calking  joints  or 
in  settlement  of  the  building. 

All  iron  pipe  should  be  tarred  with  coal  pitch  or  asphalt,  both 
outside  and  inside.  All  joints  in  cast  iron  pipe  should  be  lead 
calked.  The  calking  should  be  done  with  a  ring  of  oakum  driven 
well  into  the  hub,  and  over  this  should  be  poured  the  lead,  which 
must  be  done  in  one  run,  so  as  to  form  ;i  continuous  ring  around 
the  joint.  This  lead  when  it  has  se1  should  be  thoroughly  driven 
down  with  a  calking  chisel  and  hammer,  so  as  to  expand  againsl 
the  side  of  the  hub  and  spigot  to  form  gas  and  water  tight  joints. 

Connections  between  the  house  sewer  and  street  sewer,  ex 
cept  where  the  streets  are  of  concrete  or  brick,  or  the  connection 
of  considerable  size,  should  always  be  made  ai  an  angle  of  not 
less  than  forty-live  degrees  and  should  be  above  the  water  line 
of  the  street  sewer.  This  connection  should  be  made  with  cemenl 
or  preferably  with  connections  made  to  conned  iron  and  tile  pipe. 
Where  the  house  sewer  connects  with  the  house  drain.,  when  the  'e 


202 


PLUMBING. 


is  danger  of  tide  water  or  back  water  in  the  main  sewer,  there 
should  be  placed  a  tide  water  or  back  water  v.alve. 

House  Drain. — The  house  drain  is  all  of  thai  portion  of  the 
sewerage  system  not  included  in  the  house  sewer  which  is  hor- 
izontally placed  in  the  basemenl  or  below  the  basement  floor.  All 
pipe  for  this  portion  of  the  system  should  invariably  be  heavy 
east  iron,  coated  inside  and  outside  as  described,  with  all  joints 
hermetically  sealed  with  oakum  and  lead  as  stated  above. 
Wrought  iron  pipes  are  sometimes  used  where  they  are  suspended 
above  the  floor,  bul  they  are  not  recommended,  as  they  rust  out 
and  deteriorate  rapidly. 

The  connection  between  the  soil  stack-  and  house  drain  should 
be  made  with  fittings  which  give  an  angle  of  forty-five  degrees,  but 
this  can  be  varied  by  the  use  of  differently  angled  fittings.  Such 
connections  should  never  be  made,  however,  at  a  greater  angle 
than  forty-five  degrees,  and  "T"  fittings  should  never  be  used, 


fig.  90. 

"T"    fitting. 

because  the  sewage  tends  to  collect  at  the  base  of  the  stack.  Fig. 
90  shows  the  propel-  methods  of  making  connections,  and  also  the 
"T"  connection  which  should  not  be  used.  At  the  base  of  all 
soil  pipes,  drains,  wastes,  and  at  the  end  of  the  house  drain,  there 
should  be  placed  a  cleanoui  fitting  closed  with  a  brass  trap  screw 
ferrule  with  brass  pings,  as  shown  in  Fig.  91.  If  more  than  one 
stack  enters  a  ran  of  house  drain,  the  connection  should  be  made 
in  such  a  manner  that  the  second  stack  does  not  enter  directly 
into  the  house  drain,  but  at  one  side,  and  this  branch  should  have 
a  cleanout  at  the  foot  of  the  stack  as  described  (Fig.  !>1  ). 

There  should  never  be  sharp  turns  in  the  house  drain.  All 
such  bends  should  be  at  an  angle  of  at  least  forty-five  degrees, 
"i  with  a  large  radius,  quarter-bend.  If  the  house  drain  is  sus- 
pended, il  should  be  put  into  hangers  not  over  ten  feet  apart,  60 
arranged  as  to  allow  for  expansion  and  contraction  of  the  pipes. 


PLUMBING.  203 

Main  Drain  Trap. — Every  house  drain  should  be  provided 
with  a  main  drain  trap.  This  should  be  put  in  perfectly  level 
and  provided  with  two  eleanput  hubs  into  which  are  calked  two 
cleanout  ferrules.  This  trap  should  be  Located  jusl  inside  the 
foundation  wall,  and  the  only  fitting  intervening  between  it  and 
the  house  sewer  should  be  a  cleanout  fitting.    This  hap  is  placed 


FIG.   91. 

in  the  system  to  prevent  any  possibility  of  gas  from  the  main 
sewer  system  entering  the  building.  The  double  trap  here  de- 
scribed is  the  only  pattern  which  should  ever  be  used  (Fig.  92). 
Floor  Drains. — These  comprise  all  drains  used  for  convey- 
ing water  from  the  surface  of  floors,  whether  these  are  in  cellar. 


FIG.  92. 

basement,  or  in  rooms  above  the  basement.  Flooi  drains  should 
never  be  used  in  the  basements  or  cellars  of  hospitals,  if  it  can 
possibly  be  avoided. 

velocity  of  Plow  in  Drains.  There  are  certain  rules  which 
should  be  followed  in  the  laying  of  drains  to  insure  proper  veloc 
ity  to  the  sewage.  Drains  .should  be  laid  SO  that  "for  each  fool 
of  fall  in  the  drain,  allow  a  length  of  ten  feci  of  pipe  for  each  inch 
in  the  diameter  of  the  pipe."  'Phis  rule  will  give  to  all  pipe  such 
a  slope'  that  the  velocity  of  the  sewage  IS  about  270  feet  per 
minute,  which  is  necessary  for  perfeel  drainage.     With  a  velocity 


204  I'l  l    VI  BING. 

under  180  feet  per  minute,  the  water  flow  is  not  sufficient  to  carry 
away  the  solids,  and  with  greater  than  360  feet  per  minute,  the 

water  will  run  away  from  tli'.-  solids. 

The  house  drain  should  never  he  so  small  that  it  will  not 
readily  carry  away  all  the  discharge  into  it;  nor  should  it  he  so 
Large  that  it  will  not  he  self-cleaning.  House  drain.-  must,  how- 
ever, he  larger  than  the  largest  discharge  into  them,  and  in  hos- 
pitals should  usually  provide  for  a  maximum  removal  of  200 
gallons  per  capita  daily.  The  size  of  pipe  should  be  ''one  square 
inch  in  sectional  area  of  the  drain  for  each  fifteen  gallons  of  sew- 
age to  he  removed  per  minute." 

Fkksh  An;  Enlet. — Provision  should  he  made  for  a  fresh  air 
inlet  connected  to  the  house  drain  to  equalize  the  pressure  in  the 
system,  and  to  provide  fresh  air  circulation  in  the  drain  stacks. 
Rainleaders  should  be  trapped  directly  into  the  house  drain,  or 
should  he  run  to  a  catch  basin  which  empties  into  the  house  sewer. 

Yard  and  area  drains  should  he  constructed  of  cast  iron  with 
the  grating  surface  double  the  size  of  the  drain  pipe  which  runs 
from  the  catch  basin.  Such  drains  should  be  connected  with  the 
main  catch  basin  or  the  house  drain. 

<\\tch  Basin. — Kitchen  or  other  greasy  wastes  should  be 
intercepted  by  a  catch  basin  or  grease  trap  and  thence  conducted 
to  the  house  drain.  Catch  basins  for  receiving  wastes  should  he 
constructed  either  of  brick,  concrete  or  cast  iron.  If  of  brick  or 
concrete,  they  should  be  at  least  thirty  inches  internal  diameter 
at  the  base  and  taper  to  not  less  than  twenty-two  inches  internal 
diameter  at  the  top.  and  he  finished  with  a  stone  or  iron  cover  at 
grade  level.  The  bottom  should  be  at  least  two  feet  below  the 
invert  of  the  outlet  to  the  sewer.  The  outlet  should  be  trapped  to 
a  depth  of  six  inches  below  the  invert  of  the  outlet  to  the  sewer,  to 
prevent  the  escape  of  grease,  by  a  hood  or  trap  of  brick  and  cement 
mortar,  a  hood  of  concrete  or  one  of  cast  iron.  The  invert  of  the 
inlet  to  the  catch  basin  for  kitchen  wastes  should  he  not  less  than 
two  and  ;i  half  feet  above  the  finished  bottom  of  the  catch  basin. 

Stacks  and  Branches-  Stacks  are  designated  as  soil  and 
waste  -tacks.  Branches  to  these  are  designated  as  soil  and  waste 
pipe.  Soil  stacks  and  soil  pipes  are  used  for  the  discharge  from 
closets,  urinals,  slop  hoppers,  and  sometimes  other  bathroom  fix- 
tures. Waste  stacks  and  pipes  receive  the  discharge  from  all 
other   fixtures,   including   slop   sinks. 

Soi]  and  wastes  can  be  run  in  one  of  two  methods  one-pipe 
and  two-pipe  systems.  Pig,  04  illustrates  a  two-pipe  system  with 
the  lavatories  and  tubs  wasting  into  the  soil  stack.  In  this 
system  a  main  soil  stack  is  used,  into  which  the  discharge  from 


PLUMBING. 


205 


fc 


FIG.  93. 
( >ne  pipe  soil  s>  sfc  m 


206 


PLUMBING. 


2l 


£=% 


^ 


4J^£ 


p n. 


$°       *? 


^ 


c 


:^ 


/ 


5=^ 


t£s 


l=p 
5^ 


v    : 


u 


FIG.  94. 


I-IJ    MBIXG. 


201 


closets  is  through  a  soil  pipe,  and  the  discharge  from  the  other  fix- 
tures is  through  waste  pipes  into  the  soil  stack.    As  will  be  noted, 


FIG.  95. 

there  is  a  vent  stack,  which  branches  from  the  soi]  stack  below  the 

lowest  point  of  discharge  of  the  lowesl  fixture,  and  runs  above  the 


208  PLUMBING. 

highest  fixture  connecting  into  the  soil  stack,  or  going  directly 
through  the  roof.  In  Fig.  95  is  shown  the  method  of  venting 
waste  stacks.  This  system  is  installed  as  shown  with  a  vent  from 
th"  crown  of  each  trap  to  prevent  the  breaking  of  the  water  seal 
in  traps  by  siphonage  and  hack  pressure. 

The  one-pipe  system  eliminates  the  vent  stacks,  except  that 
the  soil  stack  must  be  run  through  the  roof,  in  the  same  manner 
as  it  must  in  any  system.  In  the  one-pipe  system,  as  shown  in 
Fig.  93,  the  fixtures  are  equipped  with  non-siphon  traps,  as  shown 
in  fig.  96.  In  this  the  water  has  a  motion  which  makes  it  self- 
cleaning,  as  all  such  traps  should  l>o.  This  system  reduces  the 
cost  of  installation  by  one-half,  and  from  a  sanitary  standpoint 
is  equal,  if  not  superior,  to  the  two-pipe  system.  It  is  not  as  ab- 
solutely noiseless  as  the  two-pipe  system,  hut  the  slight  gurgling 
noise  is  not  objectionable,  as  the  pipes  are  run  in  a  pipe  slot  away 
from  the  habitable  part  of  the  hospital,    Furthermore,  it  has  the 


FIG.  96. 

decided  advantage  of  making  pipe  slots  possible,  whereas  in  the 
two-pipe  system  thjs  is  somewhat  difficult,  owing  to  the  long  hori- 
zontal runs  necessary  to  get  to  such  a  slot.  Water  closets  on  a 
one-pipe  system  should  be  back-vented  below  the  floors,  as  shown, 
a>  these  fixtures  are  not  made  wit h  non-siphon  traps. 

Grkask  Traps. — .V  grease  trap  is  used  to  intercept  the  grease 
from  kitchen  sinks.  One  should  he  installed  at  every  kitchen  sink 
in  the  hospital,  or  at  any  sink  into  which  greasy  substances  are 
poured.  Such  traps  should  be  placed  as  close  to  the  sink  as  possi- 
ble. These  traps  should  he  built  of  enameled  iron  and  so  con- 
structed  that  cold  water  will  circulate  around  the  trap  in  an  outer 
jacket.  This  can  be  done  by  connecting  a  cold  water  supply  to  the 
jacket,  and  running  it  from  this  to  a  fixture,  so  that  the  drawing 
of  water  at  the  latter  will  cause  a  circulation  of  the  water  in  the 
jacket. 

Grease  traps  should  be  made  commodious,  their  size  depend- 
ing upon  the  amount  of  water  which  is  emptied  into  the  sink  at 
one  time. 

Blow-Off  Tanks.— These  are  installed  for  boilers  in  which 


PL.UMBING. 


200 


f? : 


tt=^ 


pig.  97. 


I'll) 


PLUIMBING 


there  is  high  pressure  steani.  Most  municipalities  make  stringent 
regulations  prohibiting  steam,  exhaust,  blow-off.  drip  and  return 
pipes  from  entering  any  sewer,  house  drain,  soil  or  waste  stack  or 
rain  leader  before  the  steam,  etc.,  is  discharged  into  a  suitable 
casl  iron  catch-basin  or  condenser,  Prom  which  a  special  vent  pipe 
not  less  than  two  inches  in  diameter  extends  through  the  roof  of 
the  building.  Thes<  tanks  must  be  properlj  proportioned  for  the 
apparatus  to  which  they  are  connected.  Outlets  from  these  tanks 
should  be  made  larger  than  the  inlet,  so  as  to  permit  the  water 
from  them  to  enter  the  sewer  at  slow  velocity,  and  to  permit  the 
replacing  of  the  hot  water  by  cold  water. 

Refbigebatob  Wastes.  In  hospitals  where  there  are  super- 
posed diet  kitchens  with  small  refrigerators,  provision  for  wast- 
ing these  is  made  as  shown  in  Fig.  97.  The  connection  at  each 
floor  should  be  made  through  an  "S"  pattern  siphon  trap,  or 
preferably   a  drum   trap   which   is  accessible  and  easily  cleaned. 


FIG.  98. 

The  fittings  in  such  a  system  and  the  connections  to  the  safes 
must  be  such  that  the  piping  is  smooth  on  the  inside.  This  may 
he  done  by  reaming  the  ends  of  the  pipe  and  screwing  them  into 
recessed  drainage  fittings. 

All  pipe  should  he  galvanized  iron  not  less  than  two  inches 
in  diameter  and  should  never  drain  directly  into  a  sewer,  but 
iido  a  sink  that  is  properly  trapped,  or  into  a  combination  floor 
drain  which  has  a  flushing  rim,  and  hot  ami  cold  water  supply 
t<>  it.  which  allows  of  thoroughly  cleansing  the  trap.  The  pipe 
should  extend  through  the  roof.  The  refrigerator  safes  can  be 
made  in  the  form  of  a  lead  box,  formed  on  bevel  strips,  as  shown 
in  Fig.  98,  or  can  he  of  cast  iron,  galvanized  type  with  a  hinged 
cup.     The  latter  can  lie  sel  flush  or  on  the  floor. 

Mechanical  Discharge  Systems.— Mechanical  discharge  for 
sewage   depends   wholly   upon   the   location  of  the  building  with 


PLUMBING.  211 

reference  to  the  street  sewer,  and  the  requirements  of  the  hos- 
pital.   These  systems  are  used  only  when  the  house  drain  is  below 
the  line  of  the  street  sewer. 

Subsoil  Dbainage.-  Where  there  is  a  condition  of  dampness 
or  a  water  level,  which  would  keep  the  foundations  and  probably 
the  basement  floor  damp,  subsoil  drainage  is  put  in.  As  stated, 
however,  in  another  chapter,  all  walls  and  basement  floors  sub- 
ject to  such  conditions,  as  also  soil  gas,  should  be  thoroughly  water 
proofed,  which  would  preclude  any  possibility  of  dampness  in 
walls  and  floors.  It  is,  however,  well  to  drain  the  water,  where  it 
is  excessive,  by  means  of  subsoil  sewers  placed  about  the  entire 
building  in  such  manner  that  the  water  which  How.-  into  them  may 
be  readily  carried  off.  These  subsoil  pipes  must  he  laid  over 
broken  stone  or  coarse  cinders,  and  over  them  again  a  bed  Crom 
eighteen  inches  to  two  feet  of  broken  stone  should  be  placed  in  the 
entire  trench,  in  order  to  facilitate  the  flow  of  water  to  the  drain 
tile.  These  drains  connect  to  catch  basins  properly  trapped,  or  o> 
the  invert  or  lower  portion  of  the  main  street  sewer. 

Testing  Drainage  Systems.— All  drainage  svstei.i^  must  be 
tested  thoroughly  at  least  twice  before  they  are  put  into  service. 
The  first  is  known  as  the  roughing  test;  the  second  as  the  final 
test,  the  former  being  applied  when  the  drainage  system  is  com- 
plete except  the  setting  of  the  fixtures,  and  the  latter  when  the  en 
tire  system  is  complete. 

There  are  two  methods  of  testing  by  the  roughing  test  i.  e., 
by  water  and  by  air.  In  the  water  test  all  openings  are  tightly 
closed,  except  those  above  the  roof,  and  the  system  tilled  with  water 
until  it  stands  level  with  the  top  of  the  pip'es  above  the  roof.  The 
openings  in  lead  pipes  should  he  closed  with  lead  disks  soidered 
on  when  the  pipes  are  installed,  and  left  until  the  fixtures  are  set 
The  openings  in  cast  iron  pipes  should  he  closed  with  mechanical 
pings — no  driven  pings  should  ever  he  used.  The  trap  openings 
should  only  he  closed  by  special  trap  fittings,  as  cementing  and 
leading  are  extremely  had  practice,  owing  to  the  fact  that  cenien! 
cannot  he  thoroughly  cleaned  out,  and  lead  requires  cutting  away, 
which  can  only  he  done  by  inserting  the  hand  with  the  cutting  t * > * » I 
into  the  trap,  making  if  impossible  to  get  a  (lean  job.  In  the 
water  test   the  system  should  he  filled  slowly  from  the  bottom.      AH 

leaking  hubs  should  he  calked  tight,  and  in  case  of  --piit  pipe  il 
should  be  removed  and  a  new  section  put  in  aid  the  entire  system, 
or  that  portion  in  which  defects  occurred,  retested.  Test  by  water 
should  he  done  as  soon  as  the  work  LS  installed. 

The  air  test  is  carried  out  much  in  the  same  manner  as  the 
wafer  test.     All   openings  are  closed,  except   one   into   which   is 


2]  2  PLUMBING. 

placed  an  air  compressor  and  an  air  gauge.  The  air  is  pumped 
into  the  system  and  the  gauge  should  register  no  drop  unless  there 
arc  defects  through  which  air  is  escaping.  This  method  is  not 
recommended  on  account  of  the  great  difficulty  in  Locating  leaks. 

Final  Tests.-  These  tests  arc  applied  after  the  system  is 
practically  complete,  the  fixtures  all  being  set.  There  are  two 
methods  of  procedure — by  smoke  and  by  peppermint.  The  latter 
Is  done  by  pouring  from  two  to  I'oui  ounces  oJ  oil  of  peppermint 
into  each  stack,  followed  b\  a  quantity  of  boiling  water  run  into 
the  stack,  plunging  up  the  latter  after  the  watei  is  poured,  and 
detecting-  leaks  by  the  sens-  of  smell:  This  is  not  as  reliable  a 
method  as  the  smoke  test,  as  there  is  no  pressure  employed,  and 
small  leaks  will  therefore  not  readily  be  disclosed  on  this  account. 

The  Smoke  Test. — The  smoke  test  is  applied  by  forcing-  some 
heavy,  pungent  smoke  into  the  system  under  pressure.  This  pres- 
sure must  not  be  enough  to  force  the  water  seal  in  traps,  but  suffi- 
cient to  force  the  smoke  into  all  pipes.  A  one-inch  column  to  bal- 
ance the  pressure  will  indicate  the  force  of  the  latter.  This  method 
will  quickly  disclost-  the  smallest  leak.  The  smoke  is  produced  in 
a  smoke  machine  made  for  the  purpose  of  smoke  tests. 

There  should  be  no  concealing  of  sewerage  pipes  in  any  man- 
ner until  the  final  tests  have  been  made,  as  it  is  absolutely  neces- 
sary that  the  entire  length  and  all  .mints  of  pipes  of  the  whole 
system  be  accessible  until  every  part  is  tested  and  secured. 

WATKK  SUPPLY. 

Installation. — The  installation  of  a  water  supply  in  hos- 
pitals should  not  be  a  mattei  precedent,  but  should  be  the  result 
of  exact  calculation  as  to  the  size  of  pipes,  their  location  and  in- 
stallation, and  the  best  methods  of  conveying  the  water  from  its 
source  or  sources  to  the  various  fixtures.  Ii  will  be  necessary  in 
doing  this  to  calculate  the  amount  of  water  approximately  re 
quired  in  the  whole  institution  for  a  given  period,  the  amount  of 
water  accessary  at  each  fixture,  and  the  velocity  and  volume  of 
the  whole  amount  which  musl  be  delivered  at  a  time.  All  of  these 
depend  upon  exact  scientific  calculations  for  the  size  of  pipe,  the 
kind  of  pipe,  the  number  of  bends  or  turns,  their  size  and  charac- 
ter, the  distance  of  the  source  of  supply  from  a  given  fixture,  the 
initial  pressure  at  this  source  of  supply,  whether  this  is  caused  by 
pumping  or  direct  pressure,  or  by  the  pressure  exerted  by  the 
weight  of  the  water. 

The  loss  «.f  head  of  water  for  bends  musl  be  calculated  by 
given  formulae.  For  straight  pipe,  the  resistance  due  to  friction 
is  in  direct  variation  to  the  length  of  the  pipe  and  "friction  varies 


PLUMBING.  213 

inversely  as  the  diameter  of  the  pipe,  ;m<i  varies  almost  as  the 
square  of  the  velocity,  and  is  entirely  independent  of  pressure." 

Water  Hammer.-  Elaving  determined  the  size  of  the  pipe, 
the  pressure  and  velocity  therein,  it  is  necessary  to  so  construct 
the  system  that  it  will  be  both  noiseless  and  fret  from  the  dang<  r 
of  bursting  pipes  and  apparatus.  The  first  requisite  in  guarding 
against  this  is  to  provide  means  to  prevent  excessive  pressure  in 
the  pipes  and  system.  This  pressure  is  caused  by  the  quick  clos- 
ing of  eoeks  on  fixtures,  ami  so  bringing  the  water  flow  to  a  sud- 
den stop.  Water  which  is  moving  through  a  pipe  at  a  know  i 
velocity  and  with  a  given  pressure  will  givean  unpad  when  the 
flow  is  suddenly  turned  off  which  is  calculated  at  from  four  time- 
to  eleven  times  the  initial  pressure. 

Mr.  Cosgrove  in  "Principles  ami  Practice  <>!  Plumbing"  says 
in  regard  to  this:  "With  a  static  pressure  of  thirty  pounds  per 
square  inch  and  a  velocity  of  eight  feet  per  second,  the  maximum 
pressure  due  to  water  hammer  when  no  air  chamber  was  used 
was  320  pounds  to  the  square  inch,  an  increase  in  pressure  of  290 
pounds  or  an  ultimate  pressure  of  almost  eleven  times  the  initial 
pressure.  At  a  velocity  of  four  feet  per  second  with  all  of  the 
other  conditions  unchanged,  the  maximum  pressure  was  about 
135  pounds  per  square  inch,  or  an  ultimate  pressure  of  loin-  and  a 
half  times  the  initial  pressure.  With  an  air  chamber  of  forty 
cubic  inches  capacity  and  a  velocity  of  eight  feet  per  second,  the 
maximum  pressure  was  about  230  pounds,  or  an  increase  of  200 
pounds  above  static.  When  an  air  chamber  ot  320  cubic  inches 
capacity  was  used,  and  with  a  velocity  of  eight  feci  per  second, 
the  maximum  pressure  produced  was  less  than  that  produced 
with  a  velocity  of  3.5  feet  per  second  when  no  air  chamber  was 
used. 

"It  will  he  observed,  however,  that  the  experiment  conducted 
with  half-inch  self-closing  basin  cock  more  Dearly  approaches  the 
condition  found  in  practice.  In  those  experiments,  the  ultimate 
pressure  was  equal  to  about  three  limes  the  initial  pressure,  while 
in  a  water  supply  system  provided  with  adequate  air  chambers  a! 
suitable  points,  and  fitted  with  slow-closing  faucets,  the  maximum 
pressure  due  to  water  hammer  should  never  exceed  double  the 
static  pressure.  The  force  of  impact  to  a  great  extent  is  depend- 
ent upon  the  time  consumed  in  closing  the  bibb.  Tims,  if  the 
force  of  impact  due  to  closing  (he  bibb  in  one  second  equals  174.45 
pounds,  the  force  due  t<  closing  it  in  half  second  would  equal 
354.9  pounds,  and  to  closing  it  in  one-quarter  second,  532.35 
pounds." 

An;  Chambers     To  prevent   this  water  hammer  and  execs- 


2\4 


PLD  MBING 


sive  pressure  in  pipes,  air  chambers  are  provided.  These  are 
usually  enlarged  pipes  exactly  designed  and  proportioned  to  re- 
ceive the  impact  of  water  pressure.  It  is  accessary  to  know  the 
velocity  of  the  water  in  the  pipe,  the  size  of  the  pipe  and  its  length, 
in  order  to  determine  the  size  of  the  air  chamber.  Exacl  calcula- 
tions are  possible  and  are  accessary.  The  air  chambers  have  be  \  \ 
used  to  some  extenl  on  axtures.  but  these  have  usually  been  ex- 
tensions of  the  supply  with  an  enlargement  jusl  above  the  take 
off  of  the  chamber,  and  lane  had  no  relation  whatever  to  the 
exact  size  necessary  to  adequately  take  care  of  the  air  pressure 
to  overcome  water  hammer.  Such  air  chambers  when  used  on 
manifolds,  in  the  rare  cases  where  they  have  been  installed,  and 
at  the  terminal  of  mains  from  which  branches  have  been  taken, 


I'M;.  99. 

have  in  almost  all  instances  been  far  below  what  is  necessary  to 
relieve  the  pipes  from  excessive  pressure. 

In  all  air  chambers  provision  should  he  made  to  give  access 
for  tin-  ail'  as  water  will  absorb  air  and  soon  exhaust  the  air  in 
die  chamber.  These  chambers  should  ho  equipped  with  pi  t  cocks 
fiii'  the  smaller  chambers  ami  stop  cocks  for  the  Larger  ones,  to 
permit  ail'  to  enter!  The  pressure  of  the  water  should  be  directly 
upon  the  aii-  chamber.  This  can  host  he  accomplished  by  putting 
such  chambers  where  they  will   receive  the  initial   pressure,  and 


PLUM  B]   -<:. 


215 


should  never  be  placed  in  a   horizontal   position  or  at   an  angle. 
\ii-  chambers  should  be  placed  in  connection  with  meters  +  o  take 
the  force  of  the  water  hammer  from  the  delicate  mechanism. 


fig.  100. 
Each  supply   of   fixtures   should   have   an   air   chamber   and 
such  chambers  should  be  placed  on  discharge  and  suction   pipes 
to  power  pumps  and  on  distributing  drums.    Two  forms  of  those 
chambers  are  shown  in  Figs.  99,  loo,  mi,  102. 


fig.  101. 
Material.  .Material  for  pipes  arc  of  several  kinds  namely, 
lead,  iron,  brass  or  white  metal.  As  all  pipes  are  subjecl  to 
pressure  and  other  stresses,  they  are  made  of  differenl  thick- 
nesses of  metal  to  withstand  such  pressure.  Pipes  should  invari- 
ably be  seamless  except  in  iron. 


216  PLUMBING 

The  materia]  to  be  used  depends  upon  several  conditions, 
pressure  in  the  pipe,  Location  of  the  pipe,  the  finish  on  the  pipe 

Lead  Pipe. — The  required  thickness  of  piping  and  the  ma- 
terial for  such  pipes  is  a  matter  of  exact  computation  by  formula. 
When  the  thickness  of  material  is  known,  the  exact  stresses  it  will 
withstand  can  be  calculated;  and  on  the  other  hand,  when  the 
stresses  are  known,  the  proper  thickness  of  material  for  pipes  can 
be  calculated,  in  such  calculations  the  same  genera!  rules  apply 
as  would  be  employed  in  computing  a  structural  member  of  the 
building,  as  described  in  the  Chapter  on  Iron  and  Steel. 

In  all  instances  there  must  he  allowed  a  factor  of  safety  in 
calculating  the  size  and  strength  of  pipe.  There  are  in  hydro- 
dynamics, as  in  steel,  computations  giving  for  live  and  dead  loads. 
The  dead  load  is  the  constant  pressure  in  the  pipe;  the  live  load 
is  one  which  i^  not  constant,  due  to  variations  in  pressure  from 


FIG.    102 

one  cause  or  another.  The  must  serious  of  these  variations  is  due 
to  water  hammer.  The  factors  ordinarily  allowed  in  pipes  are 
He-  same  as  I'm  structural  steel  namely,  six  for  live  loads  and 
four  for  dead  loads. 

Lead  pipes  •■oine  m  diiYereii'  weights  and  thicknesses,  and  are 
usually  \\>('(\  where  such  pipes  come  in  contact  with  the  ground  or 
are  lam  in  damp  places.  Lead  is  also  used  tor  supplies,  either 
painted  or  impainted,  l»nt  as  they  are  subjeel  to  rough  usage,  and 
are  pliable  and  soft,  the}  are  m  t  as  satisfactory  as  brass  tubing, 
iron  pipe,  or  white  metal  pipe  for  this  purpose.  Lead  pine  is  used 
where  the  corrosive  action  of  the  water  would  injure  either  the 
pipe  or  the  supply  if  iron  <»r  brass  were  used. 

The  classifications  of  lead  pipe  and  their  grading  from  the 
light  t<>  the  strongesi  pipe-  are  aqueduct,  extra  light,  medium. 
strong,  extra  strong,  and  extra-extra  strong.  The  commercial 
varieties  usually  employed  are  the  strong  and  extra  strong.    Most 


PH'MHUXC. 


217 


municipalities  have  regulations  requiring  the  use  of  extra  strong 

in  all  work  where  lead  pipe  is  put  in. 

Wrought  Iron  Pipe—  Like  Lead  pip*-,  iron  pipe  comes  in 
sizes  and  weights  which  ar<  adaptable  for  any  work,  it  is  manu- 
factured in  two  ways— by  rolling  the  metal  and  joining  the  two 
edges  of  the  iron,  or  butting  them  together,  as  it  i>  ordinarily 
designated;  and  by  lapping  the  edges  over  one  another  after  they 
have  been  beveled.  The  butt  jointed  tubing  is  not  as  strong  as 
the  lap  welded  tubing,  but  as  the  former  is  made  in  small  sizes 
only,  this  need  not  be  taken  into  consideration.     Iron  pipe  for 


pig.  L03. 
water  supply  is  usually  galvanized  inside  and  outside,  although 
it  is  also  treated   in   other   ways  to   prevenl   corrosion.     Water 
which  flows  through  pipes  thai  are  not  thus  protected  is  subjcci 
to  discoloration. 

The  subject  of  pressure  as  applied  to  calculations  for  wroughi 
iron  pipe  is  as  exacl  as  for  lead  pipe. 

Wrought  iron  pipes  are  used  for  water  supply  where  such 
pipes  do  not  come  in  contacl  with  the  ground.  They  are  also 
used  as  supplies  on  lixdnvs,  and  for  ilii>  purpose,  when  galvanized 
or  painted  on  the  outside  are  admirable. 


218 


PLI'.MFJING 


Brass  Pipe. —  Brass  pipe  is  calculated  in  iron  pipe  size  and 
is  seamless  tubing  made  in  stock  Lengths.  It  is  used  in  the  rough 
state,  nickel-plated  or  polished,  depending  on  its  purpose  and 
location. 

There  are  several  grades  of  brass  tubing,  but  the  ones  ordi- 
narily selected  and  hest  adapted  to  plumbing  work  are  the  stand- 
ard  and   extra    heavy    tubing  of   regular  temper. 

Safe  loads  are  calculated  for  these  in  the  same  manner  as  for 
other  piping. 

Fittings.  There  are  no  fittings  for  lead  pipe,  all  joints  being 
soldered. 

For  iron  pipe,  malleable  or  gray  iron  fittings  are  used — the 
former  for  small  pipe  and  the  latter  for  larger  sizes. 

Brass  fittings  are  made  of  cast  brass  and  are  either  rough, 
polished  or  nickel-piated,  as  the  case  may  be,  to  make  them  cor- 


FIG.   1.04. 
respond  to  the  finish  of  the  pine-  to  which  they  arc  connected. 

Valves.  Valves  are  used  in  water  supply  to  either  control 
the  water  flow,  to  check  the  water  flow,  oi  to  equalize  the  same. 
Gate  valves,  globe  valves  and  angle  valves  are  used  to  turn  off 
<>r  turn  on  the  water.  Check  valves,  as  their  name  indicates,  are 
to  check  the  flow  of  water  due  to  hack  pressure  for  one  reason 
or  another. 

Gate  Valves.-  Fig.  L03  shows  a  gate  valve.  This  is  the  hi'st 
type  of  valve  to  use  on  mains,  as  it  seats  tightly  and  positively 
when  closed  and  gives  a  full  aperture,  and  consequently  full  sweep 
to  the  water  flow  when  completely  open. 

Globe  Valves.  A  globe  valve  is  shown  in  Fig.  L04.  This  type 
although   nsed  most  extensively  has  these  objectionable  feature- 


I  LUMBING. 


219 


— diverting  the  flow  of  water,  owing  to  its  structural  design;  it 
can  be  put  on  the  pipe  in  only  one  position;  it  is  noi  reversible 
as  is  the  gate  valve;  the  disc  of  the  valve  closes  on  a  seal  againsl 
the  water  flow  or  pressure.     In  this  type  of  valve  the  disc  musl 


FIG.   105. 

be  renewed,  as  it  is  of  soft  material.     It  has  been  found  thai  in 
valves  of  this  pattern  metal  discs  will  noi  remain  water-tight. 

Angle  Valves. — Fig.  LOS  shows  an  angle  valve,  a  type  of 
valve  which  is  placed  on  the  supplies  of  each  fixture.  The  usual 
position  of  such  valves  is  shown  in  Figs.  L01,  L02. 


fig.  L06. 

Check  Valves.  Check  valves  are  of  two  patterns,  those  in 
which  the  cheek  works  by  gravity  (Fig.  106),  and  those  in  which 
a  disc  or  gate  is  suspended  in  hinge  fashion  from  the  top  of  the 
valve  (Fig.  K'T). 

These  valves  are  designed  and  installed  into  water  supplies 


22i , 


i  1.1    M6ING 


to  prevenl  water  from  flowing  in  more  than  one  direction  in  pipes. 
This  is  necessary  where  there  is  a  liability  of  hack  pressure.  In 
the  lift  valve  the  check  is  raised  by  the  flow  of  water  and  pressure 
under  the  check.  The  reverse  flow  is  prevented  by  the  pressure 
of  water  over  the  check.    The  same  action  takes  place  in  the  swing 


•  •heck  valve,  with  the  exception  that  the  disc  or  check  swings  with 
the  water  pressure  and  Hew.  and  closes  against  the  hack  pressure. 
A>  will  he  seen,  the  latter  form  of  valve  gives  a  full  opening  as 
in  tin'  gate  valve,  and  in  the  former  a  contracted  opening  results. 
as  in  the  globe  pattern  valve. 

Cocks. — The   four  general   types  of  cocks  now  in  use.  each 


fig.  L08. 

with  it-  variations,  are  the  ground  key  cock,  the  compression 
pattern  cock,  cocks  in  which  Puller  halls  are  used,  and  cocks  of 
the  self-closing  pattern. 

GrBOTJND  l\  KV  Cocks.  The  firsl  type,  LllOSe  with  -round  key.-,, 
are  aol  recommended  for  hospital  work,  except  where  they  are 
used  a-  controlling  valves  en  pipes,  or  in  place-  where  they  are 
not  used  frequently.  These  cocks  work  metal  to  metal,  and  are 
consequently   subjeel    to   the   wearing  away  of  the  metal   of  the 


PLUMBING. 


991 


key  and  the  cock,  *hicb  prevents  a  tighl  joint,  and  a  consequent 
leaking  of  the  faucet  They  are  not  adapted  to  high  pressure 
work  Moreover,  since  they  are  not  provided  with  an  chambers, 
as  are  the  self-closing  cocks,  and  owing  to  the  rapidity  with  wnicn 
they  can  be  closed,  their  use  mighl  give  rise  to  serious  derange- 
ment of  pipes  and  fixtures  (Figs.  L08,  109). 


FIG.  109. 

Compression  Cocks.— Compression  cocks  arc  ordinarily  used 
on  laundry  trays,  sinks  in  boiler  rooms,  and  kitchen  sinks  iFig. 
110)  although  there  are  types  of  such  valves  which  are  used 
on  lavatories  'Fig  Ul).    They  operate  on  the  same  principles  as 


fig.  110. 
the  globe  pattern  valve.    They  can  be  kept  in  good  working  condi 
tion,  as  they  have  a  soft  disc  which  closes  on  a  metal  seat,  this 
disc  being  removable  and  easily   replaced.     There  is  a   stuffing 
box  at  the  top,  as  well  as  a  packed  joint  to  prevent  leaking  around 

the  Tins  form  of  co.-k  is  particularly  adaptable  to  high  pressure 
■k  owing  to  its  slow  closing  action. 


wor 


.).).) 


PLUMBING. 


Ftjlleb  Cocks.     Puller  faucets  are  adaptable  to  low  pressure 

work  only,  and  in  all  cases  where  they  are  used  the  supplies  to 
fixtures  must  be  equipped  with  air  chambers,  owing  to  the  rapidity 
with  which  this  type  of  lancet  can  be  closed.  Pig.  112  shows  the 
method  of  working  these  cocks;  the  rubber  ball  presses  againsl 
the  seat.  There  are  many  types  of  these  faucets,  some  of  which 
are  shown  in  Pigs.  1 L3,  1 14. 


* 


"'#B«ir 


it-* 


FIG.   111. 

Self-Closing  Cocks— Self-closing  faucets  are  those  which 
close  by  spring  when  the  handle  is  released.  They  are  used  to 
effect  economy  in  water  consumption,  and  tor  this  reason  where 
practicable  are  adaptable  to  hospital  purposes.  They  are  espe- 
cially serviceable  where  water  is  scarce,  or  pressure  and  quantity 


fig.  L12. 

depends  on  tank  supply  for  day  use,  the  tank  filling  at  night,  and 
where  water  is  metered  and  the  rate  is  liigb  for  water  consump- 
tion.    Such   lancet-   could   not    be   u^(^\   on    fixtures   where  con- 
tinuous supply  was  necessary,  as  at  operating  sinks  where  fool 


PLUMBING. 


223 


or  knee  pedal  attachments  were  not  in  use.  as  shown  in  Pig.  LI 5. 
The  type  of  self-closing  faucet,  in  which  the  working  parts  d  » 
not  come  in  contact  with  the  water,  and  which  are  made  with  in 
air  chamber  in  the  faucet,  arc  the  host,  as  shown  in  Pigs.  L16.  117, 
118. 


J 


FIG.    113. 
Low  pattern  Fuller   faucet. 

Peessuee  Regulatoes. — All  systems  of  water  supply  which 
are  supplied  from  outside  sources  in  which  high  pressures  are 
maintained,  or  sources  which  are  subjeel  to  such  pressure,  should 


FIG.    1.14. 

"Goose  neck,"  i  r  pantrj  sink  Fullei   faucet. 

be  equipped  with  pressure  regulators.     These  keep  the  water  in 
the   building  at    normal    pressure   at    all    times,   excepl    when    the 
force  outside  is  below  the  normal  inside,  irrespective  oi   the  out 
side  pressure  excepl  as  stated. 

A  relief  valve,  or  a  safety  valve,  should  he  \,-i-(\  in  conm  ction 


224 


I'l.'-  M  31NG. 


with  such  pressure  regulating  devices  to  afford  a  means  of  relief 

to  the  water  system  in  the  hospital,  which  might  be  necessary  if 

the  hot  water  in  its  heating  apparatus  caused  excessive  pressure. 

Service  Connections. — Service  pipes  for  hospitals  should  be 


FIG.  115. 

made  in  such  manner  that  the  maximum  supply  of  water  is  at  all 
times  available.  As  most  municipalities  have  regulations  which 
do  not  permit  of  a  larger  tap  than  three-quarters  of  an  inch  to 
the  mains,  connections  must  be  made  with  multiple  service  con- 


FIG.  116. 

nections,  as  shown  in  Fig.  1 L9.  If  the  main  supply  in  the  building 
is  over  21-.  inches  in  diameter,  the  special  fittings  referred  to 
must  be  used  when  the  street   mains  are  onlv  of  moderate     size. 


PLUMBING. 


I'l'.J' 


For  small  service  pipes  and  when  the  street  main  is  extremely 
large,  the  multiple  connection  should  be  used.  Since  the  feeds 
or  taps  to  the  main  supply  are  small,  the  item  of  friction  in  these 
must  be  considered. 

Water  in  a  pipe  three-fourths  of  an  inch  in  diameter  at  a 
given  velocity  will  only  flow  with  a  capacity  one-quarter  of  thai 
in  a  pipe  of  one  and  one-half  inches  in  diameter.  These  calcula 
tions  are  based  on  the  "equations  of  pipes,"  and  such  tables 
should  be  carefully  consulted  in  making  multiple  connections.  iti 
hospitals  where  the  supply  of  water  must  be  constant,  there 
should  be  two  service  pipes,  each  of  which  would  be  capable  of 
supplying  the  building,  and  if  possible  should  be  taken  from  the 
mains  in  different  streets.     These  supplies  should  he  cross-con- 


FIG.  117. 

nected  in  the  building.    All  such  service  pipes  should  he  equipped 
with  either  stop  cocks  or  gate  valves. 

Size  of  Pipes. — The  watei  pipes  in  hospitals  should  b<  of  such 
pize  that  the  supply  of  water  is  at  all  times  plentiful  at  low  pres 
sure  to  all  fixtures.  If  small  pipes  are  used  there  will  be  the 
consequent  annoyance  of  being  unable  to  draw  water  al  one  fix 
ture  when  the  faucets  of  another  are  in  use  Moreover,  in  the 
use  of  small  pipes  the  system  is  nol  quiel  in  working.  Pipes  in 
hospitals  need  not  he  of  such  size  as  to  supply  all  fixtures  at  one 
time,  as  all  such  fixtures  are  rarely  in  use  simultaneously.  All 
that  is  necessary  is  to  design  the  system  so  that  any  one  group  of 
fixtures  may  be  adequately  supplied,  and  it  will  be  found  that  such 
provision  will  fulfill  all  requirements. 

Manifolds.-— In  buildings  in  which  the  supply  of  water  to  all 
fixtures  is  from  direct  pressure  from  the  street   main,  manifolds 


226  PLUMBING. 

should  be  installed  so  thai  all  of  the  valves  controlling  the  water 
in  the  building  arc  Located  at  one  point,  thus  facilitating  the  shut- 
ting-off  of  water  in  any  section  of  the  building  Iron,  a  central 
point. 

Tn  multiple  storied  hospitals  in  municipalities  there  is,  with 


PIG.  118. 

but  low  exceptions,  not  sufficient  pressure  from  the  water  mains 
to  give  an  adequate  supply  of  water  to  the  upper  stories,  and  for 
this  reason  tanks  are  necessary. 

Tn  smaller  hospitals  ii  is  not  always  possible  to  follow  elab- 
orate systems  for  the  simplifying  of  water  supply,  but  no  lios- 


pig.  L19. 
pita]  is  too  smal]  to  follow  some  simple  system,  which  would  make 
such  a  supply  accessible  and  easy  to  handle. 

Pipe  Shafts.  In  hospitals  of  three  or  more  stories  there 
should  be  provided  shafts  for  the  carrying  of  pipes.  These  shafts 
should  be  made  of  such  size  that  all  parts  of  their  contents  are 
accessible,  and  should  he  so  constructed  that  they  will  open  from 
floor  to  ceiling  with   hinged  doors  at  their  point  of  access.     The 


PLT7MJ3ING.  1  _  < 

running  of  pipes  in   an   erratic   manner  from   supply  to   fixture 

may  be  somewhat  more  economical  in  first  cost  -namely,  in  the 
installation — but  the  amount  of  tearing  up  and  replacing,  and  the 
consequent  inconvenience  which  occurs  when  even  one  pipe  musl 
be  removed  for  one  cause  or  another,  would  more  than  pay  Tor  a 
systematic  grouping  and  running'  of  water  supply. 

Storage  Tank  Systems.— In  the  use  of  storage  lank  systems 
two  methods  are  usually  employed.  The  firsl  applies  to  Localities 
where  through  the  excessive  use  of  Water  during  the  day.  the 
pressure  is  so  reduced  in  the  street  mains  thai  water  cannot  be 
drawn  conveniently  or  at  all  in  the  higher  stories.  In  such  in- 
stances the  night  pressure  is  usually  sufficient  to  fill  the  tank. 
which  is  put  in  the  attic  or  in  a  pent  house  on  the  roof,  thus  giv- 
ing sufficient  water  during  the  entire  twenty-four  hours.  In  such 
systems  it  is  the  custom  to  arrange  the  water  supply,  except  for 
the  hot  water,  so  that  the  lower  stories  are  supplied  by  the  direct 
pressure,  and  the  upper  stories  from  the  tank.  In  this  system 
it  is  absolutely  necessary  to  supply  the  heater  for  the  hot  water 
supply  from  the  tank  at  all  times,  for  obvious  reasons — viz.,  first, 
that  were  this  not  done  there  would  be  no  hot  water  supply  for 
the  upper  stories  during  the  period  of  low  pressure;  and.  second, 
that  there  would  be  great  danger  of  mishap  to  the  water  heating 
apparatus  should  the  supply  of  water  at  any  time  he  shut  off. 

It  is  necessary  in  hospitals  when  the  lower  floors  are  supplied 
direct  that  provision  be  made  so  that  in  case  the  water  from  the 
street  main  becomes  insufficient,  the  supply  from  the  tank  will 
automatically  give  a  supply  of  water  to  such  lower  floors. 

In  larger  hospitals,  where  the  water  consumption  i.>  relatively 
great,  the  system  of  supply  is  shown  in  Fig.  L20.  In  this  system  a 
pump  forces  the  water  to  the  storage  tank  in  the  attic,  which  tank 
may  be  supplemented  by  as  many  overflow  tanks  a-  are  required 
to  give  a  full  quantity  of  water  Tor  al  leasl  twenty-four  hours. 

Pumps. — Pump  for  this  work  can  be  one  of  the  many  types 
employed,  but  an  automatic,   motor-driven,   triplex   pump  is   the 
most  economical  and  the  mosl  positive  in  operation.    The  triplex 
pump  will  sustain  the  column  of  water  to  the  lank  to  better  ad 
vantage  than  any  other  form. 

In  the  use  of  pumps  for  water  supply  it  is  always  well  to 
lake  the  water  from  a  tank  placed  close  to  the  pump. 

Tanks. — If  steam  pumps  are  used  surge  tanks  or  suction 
tanks  must  be  employed.  This  is  done  so  as  to  prevenl  .the  reduc- 
ing of  the  pressure  in  the  mains,  and  to  prevenl  damage  to  the 
water  supply  system.     These  surge  tanks  should  be  made  large 


99* 


PLUMBING. 


FIG.  120. 


PLUMBING.  2*29 

enough  to  hold  at  least  one  day's  supply,  if  possible,  large  enough 

for  two  or  three  days'  supply. 

The  house  tanks  should  be  Located  well  above  the  highest 
fixture  in  the  building.  The  minimum  distance  between  such  fix- 
tures and  the  lowest  tank  should  he  at  least  ten  feet.  These  lank-. 
aud  as  much  of  the  apparatus  as  can  be  conveniently  placed. 
should  be  in  a  separate  room  or  pent  house,  built  in  such  manner 
as  to  prevent  freezing  of  the  water.  This  makes  it  possible  to 
systematize  the  water  supply. 

Owing  to  the  amount  of  water  that  is  used,  it  is  often  neces- 
sary to  supply  auxiliary  or  overflow  tanks.  These  should  ail 
be  connected  below  the  main  tank  with  the  main  house  supply. 

All  tanks  should  be  supplied  with  an  overflow  pipe,  which  is 
equal  in  size  in  its  discharge  to  the  greatesi  quantity  of  cvater 
which  is  brought  to  the  tank  by  the  supply. 

House  tanks  should  also  be  provided  with  a  vent  pipe  on  the 
house  supply,  and  an  emptying  pipe  from  the  bottom  of  the  tank 
connected  to  the  overflow  with  a  valve  so  placed  that  the  entire 
tank  can  be  drained.  The  supply  pipe  to  the  house  should  extend 
a  short  distance  above  the  bottom  of  the  tank  inside  of  same,  so 
as  to  prevent  the  sediment  from  entering  the  supply.  These  over- 
flow pipes  should  be  run  to  the  roof,  or  preferably  to  the  nearesl 
sink.  They  should  never  be  connected  with  the  drainage  system 
direct. 

The  size  of  tanks  can  be  safely  figured  in  their  capacity  in 
hospitals  at  one  hundred  gallons  of  water  per  day  per  capita.  A.H 
shown,  the  auxiliary  tank  as  well  as  the  distilled  water  tank  are 
equipped  with  overflow  and  emptying  pipes.  If  all  of  these  dis 
charge  into  one  pipe  (see  figure),  this  pipe  must  be  increased 
relatively  for  each  tank  as  the  latter  discharges  Into  this  pipe. 

As  shown  in  the  illustration,  for  a  system  of  water  supply, 
the  apparatus  Tor  which  is  herein  described,  the  water  !-•  broitghi 
into  a  storage  tank,  which  is  made  of  steel,  and  from  this  i.»  raised 
to  the  house  storage  tank  l>v  the  direct  connected  triplex  pump. 

A  check  valve  should  be  placed  in  the  riser  so  as  to  take  as 
much  load  off  the  pump  as  possible.  In  this  system  an  auxiliary 
tank  appears  which  is  equipped  similarly  to  the  main  house  tank, 
is  supplied  with  water  by  the  overflow  of  the  latter,  and  is  cross 
connected  to  the  main  house  supply.  A  branch  from  the  main 
riser  to  the  storage  tank,  as  also  a  branch  from  the  main  lion-.' 
supply  properly  cross  connected,  is  run  1<«  the  filter.  The  filtered 
water  is  taken  from  this  filter  to  a  storage  tank.  From  the  main 
house  supply  is  run  a  branch  at  leasl  two  inches  in  diameter, 
which  is  connected  to  the  garbage  crematory  or  i.»  a  suitable 
heater.    From  this  main  house  supply  are  also  taken  the  branches 


230  pn  vnxu. 

for  the  cold  water  supply  for  the  slop  sinks,  kitchen  sinks,  water 
closets,  slop  hoppers,  bath  tubs,  and  lavatories.  From  the  gar- 
bage crematory  for  the  house  supply  is  taken  the  hot  water  for  the 
above  fixtures,  excepl  the  water  closets,  with  proper  return  to 
the  heater  Tor  complete  circulation. 

Prom  the  filtered  water  tank  is  taken  a  supply  to  a  manifold 
as  in  the  case  of  the  cold  water  ami  hot  water  house  supply,  and 
from  this  manifold  are  taken  the  pipes  to  supply  the  sinks  in  the 
operating  rooms,  dressing  rooms,  sterilizing  rooms  and  anesthetiz- 
ing* rooms,  with  cold  filtered  water.  The  filtered  water  supply  is 
run  to  the  garbage  crematory  through  a  separate  coil,  and  the 
above  fixtures  are  supplied  with  hot  water  in  this  manner. 

There  must  be  a  return  or  circulating  pipe  on  all  hot  water 
feed  pipes,  so  as  to  give  a  continuous  supply  of  hot  wader  at  any 
fixture  immediately  upon  the  opening  of  a  faucet.  This  can  be 
accomplished  to  better  advantage  by  running  the  pipes  up  to 
supply  one  set  of  fixtures,  and  returning  the  pipes  to  supply  an- 
other set,  and  then  return  to  the  heater  as  shown. 

from  the  filtered  water  supply  a  branch  is  taken  to  a  distill- 
ing apparatus,  a  pipe  leading  from  this  to  a  condenser.  This  con- 
denser is  operated  by  a  flow  of  cold  water  from  the  main  house 
supply,  and  the  discharge  of  this  water  can  be  either  into  the  dis- 
charging pipe,  or  it  can  be  directly  connected  to  the  hot  water 
supply  as  an  auxiliary  to  the  hot  water  house  supply,  (he  water 
being  heated  in  the  process  of  condensation.  The  condensed  water 
(lows  into  a  distilled  water  tank,  which  has  an  overflow  and  dis- 
charge pipe  as  for  other  tanks.  The  distilled  water  in  the  tank  is 
hot  and  is  piped  directly  to  the  distilled  water  fixtures  in  the 
operating  and  dressing  rooms,  etc.,  as  described.  There  is  also 
a  pipe  from  this  tank  to  cooling  coils,  which  are  so  placed  (had  the 
water  in  them  is  eooled  by  ai)-  or  by  water  from  the  main  house 
supply  running  over  these  coils.  In  this  manner  the  sinks  in  (lie 
operating  department  are  supplied  with  cold  distilled  water. 
From  this  supply  is  taken  a  branch  which  is  run  through  coils 
placed  in  the  refrigerator  to  supply  the  drinking  fountains,  and 
such  other  fixtures  where  drinking  water  is  used. 

It  will  be  necessary  in  order  to  have  no  waste  of  the  iced  dis- 
tilled water  that  a  circulating  pipe  be  run  to  the  farthest  fixture, 
and  all  intermediate  fixtures  connected  with  return  stubs  to  the 
main  return  pipes. 

By  so  doing  there  is  a  continuous  circulation  which  makes 
it  possible  to  draw  cold  water  immediately  instead  of  emptying 
the  entire  supply  pipe  wherein  the  water  has  become  warm  by 
standing. 


PLUMBING. 


Filters. — The  filter  should  consisl  of  two  cylinders  connected 
by  one  operating  valve  or  manipulator.  The  construction  is  shown 
in  Fig.  121.  In  each  cylinder  there  are  two  diaphragms  aboul  two 
inches  apart,  made  of  brass  wire  cloth  backed  up  by  a  grating. 
The  space  between  the  diaphragms  is  closely  packed  with  sea 
gravel,  which  confines  the  filtering  bed  in  the  cylinders.  Animal 
charcoal,  or  bone  black  made  by  calcination  in  inclosed  vessels,  is 
the  material  used  for  filtering.  This  is  a  purifying  as  well  a-  a 
clarifying  agent,  and,  owing  to  its  buoyancy,  is  easily  cleaned. 
Owing  to  the  fact  that  fully  two-thirds  of  the  mass  of  this  material 
is  occupied  by  interstices  and  pores,  a-  against  only  one-third  in 


S0ASS  D/APHBAGM 


BON€  BLACK 


BMSS  0//)PfiMGM 


Section  of  Cylinder  Showing  Construction 


sand,  such  as  is  found  in  sand  filters,  it  is  possible  to  do  the 
filtration  without  the  us<  of  coagulants.  Alum  is  necessary  in 
sand  filters  as  a  coagulant  ><i  gather  this  sedimenl  in  such  coarse 
particles  that  it  will  not  pass  through  the  interstices.  Che  quan- 
tity of  alum  necessary  to  clarify  water  varies  from  day  to  day 
with  the  changing  conditions  of  the  water  supply.     It  can  only  ho 


.,•>., 


PLUMBING. 


determined  by  chemical  analysis,  which,  of  course,  is  not  prac- 
ticable under  ordinary  circumstances.  Any  excess  of  alum  in 
water  used  for  drinking  is  prejudicial  to  health,  and  as  there 
would  certainly  be  an  excess  almost  constantly,  its  use  in  niters 
is  condemned  by  ail  medical  authorities.  Filters  in  which  alum 
i-  used  are  all  the  more  dangerous  because  they  deliver  water 
that  is  brilliant  ami  sparkling,  and  there  is  a  popular  tendency 
to  regard  clear  water  as  pure.  That  is  one  reason  why  too  much 
stress  cannot  be  laid  upon  the  danger  of  alum  clarified  water. 
Neither  doo  the  alum  process  render  water  suitable  for  bathing. 
Laundry  or  manufacturing  purposes.  It  makes  the  water  i;hard," 
releases  free  sulphuric  acid  in  large  quantities  and  greatly  in- 
creases the  incrust.it ion  when  the  water  is  used  for  steam  boilers, 
causing  diminished  efficiency  and  higher  fuel  cost. 

All  filters  should  be  constructed  with  a  deep  filtering  bed,  so 
that  the  water  will  remain  longer  in  contact  therewith  and  thus 
become  clearer  and  purer.  Sand  filters  are  impaired  in  their 
usefulness  by  severe  changes  in  temperatuie. 

in  using  the  double  cylinder  filter  the  cleansing  process  can 
be  made  automatic,  and  does  not  require  the  turning  of  the  crank 
or  other  manual  Labor  to  clean  the  filtering  bed.  This  is  an  ad- 
vantage also  over  the  stone  filter,  in  which  the  filtering  medium 
must  be  scraped  by  the  turning  of  the  stone  and  the  consequent 
wearing  thereof,  ami  causing  in  time  the  replacing  of  the  filtering 
stone. 

The  cleaning  process  is  as  follows:  The  filtered  water  from 
one  tank  is  run  through  the  opposite  tank  by  turning  the  manipu- 
lator in  a  position  where  this  result  is  obtained.  The  water  fil- 
tered in  the  first  cylinder  washes  all  of  the  impurities  from  the 
filtering  bed  of  the  second  by  reversing  the  How,  the  water  from 
the  second  cylinder  being  carried  into  the  waste. 

In  using  bone  black  filters  no  chemicals  are  required;  each 
cylinder  is  washed  with  filtered  water  only;  the  supply  of  filtered 
water  is  not  cut  off  during  the  washing  process.  The  water  can 
be  singly  or  doubly  filtered;  the  bacterial  efficiency  is  not  reduced 
after  washing.  Bone  black  also  removes  sulphuric  acid  and  iron, 
and  in  consequence  pipes  and  fixtures  are  not  affected  by  these. 

Garbaoi  Crematories  ami  Wateb  ili.Mii;>.  The  object  of 
the  garbage  crematory  is  to  supply  a  cheap  ami  effectual  method 
of  disposing  of  refuse.  Where  there  is  a  Larg<  amount  of  such 
refuse  Hie  consumption  of  coal  for  the  raising  of  water  to  the  re- 
quired temperature  for  use  in  a  hospital  is  small.  None  of  these 
crematories,  however,  wiil  operate  on  refuse  consumption  alone, 


PLUMBING.  233 

and  it  is  necessary  to  supplement  this  by  coal.     En  Large  plants 
the  water  from  these  crematories  is  as  •<!  for  feed  water. 

Dr.  McCullom  says:  "Twenty-five  years  ago  the  destruction 
of  garbage  by  fire  commenced  to  receive  the  attention  of  physi- 
cians and  sanitary  engineers,  and,  like  every  advance  in  science, 
this  method  was  bitterly  opposed  on  economical  principles,  as 
well  as  on  account  of  the  offensive  odors  resulting  from  combus- 
tion. In  the  refuse  from  wards,  we  have  only  to  deal  with  rub- 
bish and  garbage,  such  as  paper,  soiled  dressings  and  mattresses. 
Much  has  been  said  regarding  the  expense  of  the  disposal  of 
refuse  by  cremation,  and  an  important  factor  in  increasing  the 
expense  is  the  cost  of  collection,  but  this  docs  not  apply  to  hos- 
pital refuse,  as  it  is  not  transported  any  distance. 

"The  object  to  be  sought  is  a  cheap,  effectual,  and  not  too 
complicated  method  of  disposing  of  the  refuse  from  the  wards. 
Where  a  large  amount  of  refuse  is  to  be  destroyed,  the  heat  gen- 
erated by  its  combustion  can  be  utilized  to  a  certain  extent  in  the 
production  of  steam  or  hot  water." 

In  commenting  upon  the  necessity  of  cremation  oi  garbage 
and  refuse  from  hospitals  for  treating  infectious  diseases.  Dr. 
McCullom  further  states  that  "No  case  occurred  within  an  eighth 
of  a  mile  of  the  hospital.  Sixty-eight  cases  occurred  within  a 
quarter  of  a  mile;  within  a  half  mile  seventy-one  cases,  seventy- 
five  cases  within  three-quarters  of  a  mile,  and  seventy-two  cases 
within  a  mile.  Without  going  into  this  subject  too  much  in  detail, 
it  is  sufficient  to  say  that,  during  the  past  ten  years,  in  which 
time  more  than  24,000  cases  of  infectious  diseases  were  treated,  in 
no  instance  can  the  infection  be  traced  to  the  hospital.  The  result 
is  due,  without  doubt,  in  a  great  measure,  to  the  fact  that  ail  the 
refuse  matter  from  the  wards  is  burned  on  the  premise- ,  for  there 
can  be  no  doubt  that  where  hospitals  for  infectious  diseases  have 
apparently  been  spreaders  of  contagion,  there  has  been  Lack  of 
care  in  the  disposal  of  the  refuse." 

The  subject  of  garbage  cremation  for  the  supply  of  feed 
water  to  power  plants,  commonly  known  as  i  hernial  storage,  is 
too  comprehensive  to  explain  in  this  volume.  There  -are  books 
on  this  subject  which  give  the  entire  detail  of  the  ways  and  means 
of  obtaining  results.  Such  furnaces  are  too  Large  for  the  ordi- 
nary hospital,  and  are  used  only  where  high  pressure  plants  are 
installed  and  forced  drafts  can  be  obtained  readily.  Crematories 
installed  for  the  sole  purpose  of  destroying  refuse  without  ref 
erence  to  the  economic  principles  of  conserving  the  heat  are  not 
recommended.  Crematories  will  serve  the  purpose  of  refuse  de 
struction  as  well  when   the  products  of  combustion  are  utilized 


234  PLUMBING. 

to  heat   the  water  supply,  as  they  will   when  all  of  this  heat  is 
wasted. 

All  crematories  constructed  for  the  utilization  of  the  heat 
have  the  same  primary  principles  as  those  which  are  made  for 
destruction  alone  namely,  the  converting  of  refuse  into  fuel; 
that  is.  firs1  drying  the  garbage  and  refuse  and  then  burning  it. 
In  the  types  ordinary  to  hospitals,  crematories  are  built  with,  two 
chambers,  the  upper  being  divided  from  the  lower  by  garbage 
grates.  These  crematories  come  in  all  sizes,  from  those  used  in 
the  smallesl  to  the  large  double  crematories  for  the  largest  in- 
stitutions. 

Thc\  are  built  in  several  ways,  either  oi  steel  with  an  inner 
and  outer  shell,  or  brick,  set  in  the  same  manner  as  are  furnaces 
lor  boilers.  The  steel  double  shell  type  has  a  water  space  around 
the  entire  crematory  between  the  -hells.  The  brick  set  type  is 
made  with  water  tubes  in  the  lower  or  combustion  chamber,  which 
extend  along  both  sides  and  rear.  Of  the  latter  there  are  also 
varieties  in  which  there  is  a  garbage  pan  fixed  in  a  slanting  posi- 
tion, upon  which  the  garbage  and  refuse  is  placed  through  a  side 
door.  The  coils  are  carried  along  both  sides  of  the  pan  and  are 
crossed  underneath  in  the  rear,  in  order  to  absorb  the  heat  from 
refuse  and  garbage,  as  well  as  the  heat  from  the  coal,  as  it  travels 
through  and  over  the  garbage  pan.  The  principle  is  to  gradually 
hum  or  consume  the  refuse  at  the  same  time  that  the  products  of 
combustion  arc  absorbed  on  their  travel. 

In  the  ordinary  type  the  garbage  and  refuse  is  placed  upon 
the  bars,  and  the  beat  from  the  fire  in  the  lower  chamber  dries 
this  until  it  is  converted  into  fuel. 

Crematories  are  buiH  with  continuous  circulating  coils,  or 
with  coils  connected  to  the  inner  shell,  if  they  are  built  entirely 
of  steel.  The  upper  or  garbage  grate  should  be  hollow  tubing,  the 
lower  -rate-  of  the  ordinary  rocking  kind.  There  should  be  suffi- 
'•'»  nt  clean. »ut  doors  in  all  crematories,  and  these  and  all  othe* 
uoors  in  the  apparatus  should  '-lose  tightly.  A  good  sized  chim- 
ne_\  or  flue  must  be  provided  so  as  to  give  sufficient  draft  to  make 
the  combustion  complete,  and  to  carry  off  the  surplus  gases. 

Where  there  are  two  sets  of  coils  necessary,  as  in  heating 
water  for  house  supply  and  the  filtered  water,  the  crematory  musl 
be  of  sufficienl  size  to  do  this  work  properly.  In  this  type  the 
coils  are  laid  alternately. 

The  furnace  for  the  double  system  could  be  of  the  all-steel 
pattern,  in  which  the  space  between  Bhells  could  be  utilized  for 
one  system  with  the  garbage  urate  as  auxiliary  to  this,  and  sep- 
arate coils  put  into  the  furnace  for  the  second  system.    It  will  be 


I'Ll    M  IHNG. 


260 


found  possible  in  some  eases  that  after  the  fires  in  crematories 
are  started  the  refuse  will  supply  sufficient  heat  for  all  purposes, 
but  such  eases  are  s<,  rare  that  they  are  nol  to  be  take.,  into  con- 
sideration. Coal  or  wood  consumption  is  necessary,  the  advan- 
tage in  crematories  lying  in  the  fad  thai  the  savin-  in  such  fuel 
is  considerable. 

Water  Supply  fob  Small  Hospitals,  Water  supply  tor  small 
hospitals  may  be  obtained  as  described  for  Larger  hospitals  in  sim- 
plified form.'  A  storage  tank  can  be  placed  is  the  attic  to  be  filled 
by  the  municipal  supply,  by  small  electric  pumps,  or  by  wind 
pump-.  Gas  and  gasoline  engines  are  not  recommended  for  hos- 
pitals, as  they  are  noisy  in  operation  and  are  not  wholly  depend- 
able. .      , 

In  the  installation  of  systems  for  smaller  hospitals   the  nrsi 
requisite  is  a  plan  for  the  general  layout  and  distribution  which 


fig.  122. 
is  economical  and  direct.     Wha1   nas  been  said  of  sucb  systems 
lor  larger  hospitals  applies  as  well  to  the  smaller  institutions. 

Outside  Tanks.  Storage  tanks  of  the  ordinary  type  placed 
over  a  wind  pump  are  not  recommended,  as  there  is  always  a  lia- 
bility of  freezing  in  winter,  and  moreover  in  summer  the  water 
from  such  tanks  is  warm.  Provision  should  be  made  in  sucb  a 
system  for  placing  the  lank  in  the  attic  of  the  building. 

Tank  System.     Tin    besl  method  for  obtaining  water  where 

there  is  no  municipal  supply  is  by  the  pneumatic  tank  system. 

This  consists  of  a  lank  into  which  is  forced  wale,-  under  pressure, 


236  PLUMBIXG. 

either  by  wind,  electric  pumps  or  gasoline  engine  and  pump.  The 
general  operation  of  these  systems  is  sure  and  direct,  and  they 
are  besides  very  simple  in  installation  and  maintenance,  as  shown 
in  Fig-.  122.  This  outfit  should  be  connected  as  shown  in  the  above 
illustration.  Air  may  be  admitted  to  the  lank  by  opening  the  pet 
cock  Q.  This  will  allow  the  air  to  pass  through  the  air  pipe  E 
into  the  suction  pipe  S.  From  here  it  is  pumped  into  the  tank  by 
the  pump  cylinder  C  and  pump  B.  The  air  pump  F  must  join 
the  suction  pipe  S  above  the  water  level  in  the  well,  ami  the  cylin- 
der must   not   he  under  water. 

When  the  system  is  first  installed  enough  water  must  be 
pumped  to  seal  the  openings  on  the  bottom  of  the  tank.  The  valve 
Q  is  then  opened  and  air  pumped  until  the  gauge  shows  a  pressure 
of  ten  pounds.  This  may  take  some  time,  hut  unless  air  is  allowed 
to  escape  from  the  tank  it  need  not  he  done  again.  The  air  valve 
should  then  he  closed  and  water  pumped  into  the  tank.  When  the 
tank  is  half  full  of  water  the  pressure  will  be  30  pounds.  This  is 
the  correct  proportion.  Any  time  that  the  tank  may  he  half  full 
of  water,  the  pressure  gauge  should  register  thirty  pounds,  and  if 
it  is  less,  the  pet  cock  should  he  opened  and  air  pumped  until  the 
gauge  shows  :'»(!  pounds  pressure.  Either  a  regulating  cylinder 
or  a  relict  valve  should  be  used  upon  the  system  to  prevent  ex- 
cessive pressure  upon  the  pumping  fixtures.  When  a  pressure  of 
50  pounds  is  attained  the  regulating  cylinder  K  will  puli  the  wind- 
mill out  of  gear,  thus  limiting  the  pressure.  The  weight  P  will 
pull  the  mill  into  gear  again  when  the  pressure  has  decreased. 

FIXTURES. 

Location. — Tn  selecting  fixtures  for  hospitals,  it  is  highly 
essential  that  only  those  he  installed  that  have  been  found  to  he 
specially  fitted  for  their  ultimate  purpose,  and  which  may  he  ac- 
complished without  sacrificing  then-  artistic  effect.  While  in  no 
way  disparaging  the  effort  toward  sightly  and  artistic  installa- 
tions of  fixtures,  showy  fixtures  put  in  with  these  objects  in  view- 
are  to  be  discouraged.  There  are  two  tendencies  w  hich  are  equally 
had  the  one  results  in  show  withonl  utility,  greatly  increasing 
the  cost  of  keeping  clean;  while  the  other  tendency  is  to  secure 
only  utility,  and  to  make  every  detail  absolutely  plain,  giving  the 
institution  a  prison-like  appearance  that  repels  the  very  class  of 
people  thai  should  he  attracted  and  that  can  he  most  benefited  if 
attracted.  The  main  objeel  to  he  attained  is  the  placing  of  inex- 
pensive, thoroughly  practical,  handsome  and  efficient  fixture-, 
which  can  he  easily  cleaned  and  •  ontrolled. 

Fixtures  may  he  grouped  as  follows: 


PLUMBING. 


237 


1.  Bathroom. 

2.  Toilet  room. 

3.  Operating  room. 

4.  Kitchen  department. 

5.  Laundry. 

6.  Domestic  supplies. 

7.  Laboratory. 

8.  Hydro-therapeutic. 

In  the  classification  of  bathroom  fixtures  would  be  water 
closets,  bath  tubs,  slop  sinks,  slop  hoppers,  individual  laundry  tabs 
and  shower  baths  not  therapeutic. 


fig.  123. 

Toilet  rooms — Lavatories  and   individual    water  closets. 

Operating  rooms — Sinks  for  these,  dressing  rooms,  anesthetiz- 
ing rooms,  sterilizing  rooms. 

Kitchen  department — Kitchen  sinks,  butler's  pantry  sinks, 
and  vegetable  sinks. 

Laundry — Laundry  tubs. 

Hydro-therapeutic-   The   entire   equipmeni    Tor   such    rooms. 

Domestic  supplies     Drinking  fountains 

While  it  is  possible  and  often  preferable  to  divide  the  fixtures 

-namely,  to  place  them  in  separate  rooms,  as,  f«>r  example,  slop 

sinks  and  slop  hoppers-   they  are  here  classified  as  stated  because 


238 


I'M    IfBING. 


they   arc   more  generally   placed   in    the   bathroom,   as   shown    in 

Pig.  125. 

Private  bathrooms  in  connection  with  suites  or  single  rooms 
would  conic  partly  under  the  classification  for  toilel  rooms,  as 
lavatories  arc  placed  in  these  instead  of  sinks. 


/ 


FIG.    124. 

In  operating  rooms,  dressing  rooms,  etc.,  as  classified,  as 
also  in  general  bathrooms,  lavatories  should  never  be  used.  In 
bathrooms  the  fixtures  can  be  arranged  as  shown  in  the  illustra- 
tion. 

Bath  Tubs. — The  bath  tubs  should  always  stand  Tree  so  thai 
they  are  accessible  from  ail  sides.    Such  tubs  can  be  of  porcelain 


PLUM1UXO. 


239 


or  enameled  iron.  In  either  case  they  should  be  tubs  with  solid 
bases,  extending  below  the  finished  floor,  as  shown  in  Fig.  1.23, 
with  an  enameled  iron  tub,  and   Pig.   124,  a  solid  porcelain  tub. 


fig.  125. 
These  illustrations  merely  show  the  met  hod  of  setting;    for  loca- 
tion of  such  tubs,  see  Fig.  125. 

Porcelain  tubs  are  in  no  way  superior  to  good  enameled  iron 
tubs,  and  are  considerably  more  expensive. 

The  fitting  for  tubs  should  consist  of  bell  supply  fixture  and 
standing   waste,   as   shown.      This    leaves   the  entire   inside   of   the 

tub  free  and  gives  easy  access  to  all  working  parts.     Moreover, 

the  standing  waste  can  he  easily  removed  and  cleaned.  All  fittings 
for  these  tubs  should  be  made  of  nickel-plated  h«a\\  brass  tubing 
and  brass  castings,  or  of  white  metal  tubing  and  castings.  The 
tubs  should  be  trapped,  as  should  also  each  fixture  throughout  the 


240 


PLUMBING. 


hospital.  Bath  tub  traps  arc  of  two  kinds,  the  drum  trap  of  lead 
or  brass,  which  is  sel  below  the  floor  level  with  a  trap  screw 
ob  a  level  with  the  finished  floor ;  and  the  nickel-plated  brass  trap, 
which  sets  above  the  finished  floor,  as  shown  in  Pig.  L26. 

W'ati.i;  Closets.     Water  closets  are  of  two  types — those  with 
an   individual  tank  for  each  closet,  ami  those  which  operate  by 


fig.  126. 

pressure  from  a  main  roof  tank,  or  by  direct  pressure,  if  this  is 
sufficient.  All  water  closets  without  exception  in  hospitals  should 
he  siphon  jet  closets.  For  sanitary  reasons  all  closets  should  be 
of  the  wall  type,  as  shown  in  Pig.  127.  This  closel  sets  completely 
free  Prom  the  floor  and  close  to  the  wall  and  should  be  set  into 
the  tile  or  marble  wainscot.    Tn  setting  closets  of  the  floor  typo, 


pig.   127. 

they  >lionld  he  secured  to  the  floor  ami  to  the  soil  pipe,  a^  shown 
in  Fig.  128,  or  in  Fig.  129.  The  former  consists  of  a  conical  shaped 
asbestos  gasket,  which  assumes  an  inclined  position  between  the 
connecting  parts,  becoming  a  powerful  compressive  lever  during 
the  tightening  process,  forcing  it  against  the  closet  outlet,  ami 
againsl  the  wall  of  the  floor  flange,  making  a  positive  gas  and 
water  tight   joint,   withoul   the   use  of  rubber,  putty  or  cemeut". 


PLUMBING 


241 


Fig.  129  shows  a  closet  screw  connection  in  two  parts,  the  lower 
portion  of  which  is  fastened  to  the  floor  by  means  of  screws  and 
soldered  to  the  soil  pipe.  The  upper  half  is  connected  to  the  bowl, 
and  a  specially  prepared  asbestos  washer  is  forced  between  the 


fig.  128. 

earthenware  and  brass  connection..    The  two  sections  of  the  con 
nection  are  then  screwed  together  until  the  closet  is  Hush    on  the 
floor  surface.     While  enameled  iron  seats  are  the  mosl   sanitary 
to  use  on  hospital  water  closets,  they  are  objectionable,  owing  to 
the  fact  that  they  are  exceedingly  cold. 

In  using  the  wall  form  of  closet,  provision  must  be  made  for 


fig.  129. 

bolting  the  fixture  to  the  wall,  the  connection  being  the  same  as 
described  for  floor  closets,  shown  in  Pig.  129. 

The  individual  tank  closel  needs  no  special  mention,  except, 
that  the  (lush  pipe  from  the  tank  to  the  close!  should  be  al  leasl 
one  and  one-half  inches  inside  diameter.  Either  the  tank  nv  push 
button  closel  can  be  operated  automatically. 

Where  the  water  supply  is  sufficient  al  all  times  the  push 
button  or  level-  type  flushing  valves  are  recommended.  The  Mush- 
ing valve  is  the  most  economical  form  of  all  devices  in  its  con 
sumption  o'  water.  Supplies  to  these  valves  should  never  be 
less  than  one  and  one-half  inches  in  diameter,  and  two-inch  pipes 
are  preferable.     The  water  closet   should  invariably  be  made  of 


242 


PLUM  B]  STG 


vitreo  ;s  war;1.    The  old  sty]e  enameled  iron  closet  is  neither  sani- 
tary nor  practicable. 

Slop  Si"nks —  Slop  sinks  should  be  sufficiently  large  to  con- 
veniently admit  a  large  pail.  These  can  be  of  porcelain  or  enam- 
eled iron,  but  owing  to  their  rough  usage  the  latter  is  preferable. 
These  sinks  should  be  equipped  with  a  strap  standard,  as  shown 


S 


'"■    I-'——. 


■ 


FIG.  130. 

in  Fig.  L30.  They  can  be  made  with  a  brass  ring  to  protect  the 
enamel,  but  with  ordinary  care  this  would  not  be  necessary.  The 
water  supply  to  these  sinks  should  consist  of  a  combination  faucet 
of  heavy  brass,  with  a  long  spout  with  a  bucket  hook,  and  the 
entire  fixture  firmly  braced  by  a  wall  support.  The  sink  should 
have  a  plug  strainer,  which  will  admit  of  its  being  filled. 


PLUMBING 


243 


Slop  Hoppers. — These  fixtures  in  their  improved  form  have 
but  recently  been  introduced  for  hospital  use.  The  old  type  had 
not  a  water  seal  and  it  was  impossible  to  dilute  the  contents  of 
bed  pans  which  were  poured  into  them,  and  in  consequence  they 
were  extremely  malodorous  until  they  were  flushed,  which  could 
not  be  done  quickly.  In  their  present  form,  as  shown  in  Figs. 
131  and  132,  the  entire  contents  of  the  bed  pan  is  diluted  at  once, 
and  the  flush  being  exceedingly  strong  carries  away  all  the  diluted 
material  practically  without  odor.  They  should  be  so  arrange. I  as 
to  have  a  long,  continuous  Hush.  Besides  the  strong  siphon  jet  and 
consequent  rapid  discharge,  there  is  a  heavy  flushing  rim  supply- 
ing a  long  and  copious  flow  over  the  entire  inside  of  the  bowl. 

These  fixtures  should  always  be  made  of  vitreous  ware,  as  is 
the  case  with  water  closets,  for  they  are  essentially  an  enlarged 
type  of  the  latter,  and  should  also  be  siphon  jet  in  all  eases.    These 


fig.  131. 

hoppers  should  be  supplied  with  a  long  spouted  faucel  as  de- 
scribed under  slop  sinks;  the  bucket  hook  may  be  omitted.  These 
hoppers  are  secured  to  the  floor  in  the  same  manner  as  described 
for  water  closets. 

Wash  Trays. — It  is  necessary  in  mosl  instances  to  have  at 
least  one  wash  tray  or  tub  on  each  floor.  These  can  be  made  of 
porcelain,  enameled  iron  or  soapstone.  They  should  be,  as  far  as 
possible,  in  one  piece. 

Shower  Baths.— The  Latitude  in  the  selection  of  shower  baths 
is  so  great  that  no  attempl  is  made  to  describe  fixtures,  bul  gen- 
eral conditions  are  such  that  they  musl  be  carefully  observed.  1; 
is  recommended  thai  showers  of  the  simple  ami  inexpensive  forms 
he  used  in  all  bath  rooms.  These  may  consist  of  merely  supplies 
with  a  head  spray  and  an  overhead  ring  with  a  curtain,  the  whole 
apparatus  being  placed  over  the  tub.     For  special  showers,  such 


244 


PLUMB]  \<; 


ms  are  used  in  doctors'  dressing  and  toilet  rooms,  it  is  customary 
to  install  a  full  shower  apparatus.  The  stall  containing  the 
shower  can  be  buill  with  sides  of  marble,  slate  or  glass.  The  floors 
of  such  stalls  can  be  buill  of  any  of  these  material-,  or  of  tilt  or 
cement,  but  they  must  be  properly  countersunk  and  sloped  to  the 
central  drain.  It  will  be  necessary  in  all  instances  to  put  under 
the  floor  of  whatever  material,  except  cement,  a  lead  saiing.  The 
drain  in  these  floors  should  he  Hush  with  the  top  surface,  and  of 
sufficient  size  to  carry  off  the  water  as  quickly  as  it  flows  to  it. 
The  shower  to  be  used  depends  entirely  upon  the  amount  available 
for  the  apparatus. 


fig:  132. 

It  is  customary  to  equip  all  showers  with  mixing  chambers. 
These  are  in  the  form  of  cylinders,  into  which  the  hot  and  cold 
water  are  introduced  from  opposite  directions,  for  the  purpose  of 
thoroughly  mixing  and  producing  a  uniform  degree  of  heat.  If  it 
were  possible  to  control  the  How  of  both  the  hot  and  cold  water. 
the  desired  results  could  be  obtained,  but  this  is  not  possible,  and 
therefore  these  chambers  are  practically  useless.  Several  forms 
of  these  chambers  have  been  invented  to  overcome  the  objection- 
able features,  the  government  having  adopted  a  non-scalding  valve, 


PLUM  HI  x<; 


245 


which  consists  of  a  single  valve,  so  arranged  thai  the  cold  water 
must  be  turned  on  before  the  hot  water  can  flow.    This  makes  it 

impossible  to  turn  on  the  full  head  of  hoi  water  before  the  cold 
water  is  introduced  into  the  shower,  and  so  prevents  accident 
through  the  introduction  of  scalding  water.  The  valve  is  not 
wholly  successful,  however,  in  the  absolute  control  of  temperature, 


CO 


and  while  the  safety  feature  is  admirable,  it  lacks  the  requisites 
of  a  uniform  temperature  control.    There  has  been  introduced  a 

system  for  the  absolute  control  of  water  for  showers,  which  con- 
sists of  automatic  controlling  valves,  arranged  in  such  ;1  manner 


246 


PLUMBING 


that  the  pressure  is  always  uniform  al  the  showei  bead.  A.side 
from  the  automatic  calves,  the  apparatus  lias  a  cylinder  so  ar- 
ranged that  the  proper  temperature  of  water  is  produced  in  this 
cylinder,  the  whole  being  controlled  by  one  valve  which  makes  it 


■J 


ZrJL 


<V\A~\V»J< 


4^ 


jpp** 

FIG.  134. 

practically  impossible  for  the  temperature  to  vary,  and  also  makes 
it  a  non-scalding  valve,  as  the  water  firsl  introduced  into  it  is 
cold. 


PLUM  BING 


247 


Lavatories— Lavatories  should  be  used,  in  hospitals,  only  in 
toilet  rooms  and  private  bath  rooms  in  connection  with  other 
rooms.  Fig.  133  shows  the  general  arrangemenl  of  a  private  bath. 
Toilet  rooms  are  placed  in  connection  with  administration  rooms 


/ 


• 


FIG.   !•>•). 

and  rooms  for  staff  officers.  They  all  fellow  the  same  genera] 
rule.-  for  fixtures.  Tubs  in  private  bath  rooms  should  be  the  same 
as  those  in  general  bath  rooms,  foil,. win-  the  same  rules  for  the 
installation  of  fixtures.     Water  closets 


these  rooms  should  be 


248 


PLUMBING 


of  the  type  West  suited,  hut  preferably  the  wall  pattern  as  de- 
scribed, with  lever  or  button  valve  supply,  where  sufficient  water 
i>  available  to  operate  these. 

Lavatories  for  private  baths  and  in  other  places  in  the  hos- 
pital where  these  are  used  should  be  either  enamel  ware  or  vitre- 
ous ware.  The  latter  are  probably  the  best,  as  they  are  absolutely 
aon-absorbent,  and  exceedingly  durable.  These  fixtures  should  be 
of  the  Integra]  type,  in  which  the  back,  slab  and  bowl  are  east  in 


fig.  L35A. 

one  piece,  if  they  are  to  be  placed  against  the  wall,  as  shown  in 
Pig.  L34.  [f  they  are  to  stand  free  where  the  walls  of  the  room 
are  tiled,  they  can  be  of  the  type  shown  in  Fig.  135. 

These  lavatories  should  be  equipped  with  faucets  as  described, 
and  traps  of  the  non-siphon  pattern,  it'  these  are  necessary. 

Opehai  i.v;  ')'.;-. \i;tm knt  Fixtures. — For   a    number   of   vears 


I'LTM  KINO 


249 


there  Ik i a  been  a  growing  tendency  to  exclude  from  the 
operating-  room  aJJ  plumbing  and  lighting  fixturea;  in 
fact,  stationary  fixtures  for  any  purpose  that  could  pos- 
sibly be  dispensed  with.  This  precaution  came  from  the  fear  of 
having  objects  in  the  operating  room  which  could  noi  be  easily 
and  perfectly  disinfected.  There  was  also  the  fear  of  contaminat- 
ing- the  operating  room  air  by  sewer  gas.  through  the  -ewer  con- 


4> 


CO 


i  atar- 


FIG.    136. 

nections.  These  theories  resulted  in  much  inconvenience  to  the 
surgeon,  his  asaiatants  and  nuraea,  in  the  performance  of  their 
work  during  operations.  The  protection  which  modern  plumbing 
affords  against  sewer  gas  infection  is  so  perfect  thai  this  danger 
is  now  completely  eliminated,  and  it  is  perfectly  safe  to  have  run 
ning  water  in  the  operating  rooms.  Aside  from  these  fixtures, 
it  is  probably  best  to  have  no  stationary   fixturea  excepl    those 


250 


PLUMBING 


required  for  artificial  Lighting,  which  detail  is  discussed  under  sep- 
arate heading. 

!n  the  operating  and  dressing  rooms  sinks  should 
be  of  good  size,  made  of  enameled  iron,  vitreous  ware 
or     porcelain.       These     sinks     should     be    deep     so     that     the 


ra 


\{h  rfb° 


10 


wash  l»<»wls  can  be  placed  into  them  conveniently.  In 
operating  rooms  they  can  be  arranged  for  hot  and  cold,  filtered 
and  distilled  water,  respectively.  The  supplies  should  be  eon- 
trolled  by  either  pedal  valves,  as  shown  in  Fig.l35A,or  knee  action 


PLUM  I  MM. 


251 


valves  as  shown  in  Fig.  L36,  and  the  water  either  distilled  or  fil- 
tered, both  hot  and  cold,  should  be  supplied  to  the  sink  through 
a  single  spout  for  each  kind  of  water.  The  waste  should  also  be 
operated  by  a  pedal  or. knee  action  lilting. 

There  is  a  distinct  advantage  in  using  free  basins  in  a  sink 
instead  of  having  stationary  basins,  because  these  loose  basins 
can  be  easily  sterilized  by  boiling  and  can  be  kept  on  hand  in 
quantities. 

It  is  really  better  to  have  the  water  come  through  one  spout 


in,.  138. 

so  that  it  can  be  mixed  to  make  the  proper  temperature  for  wash 
ing  under  running  water 

In  the  sterilizing  room  should  be  placed  a  sink  lor  washing 
instruments,  constructed  like  an  ordinary  sink,  bul  winch  has 
instrument  trays  at  either  end,  which  arc  an  integral  part  of  the 
sink.    The  lancets  should  he  placed  high  enough  over  this  fixture 


252 


PLUMBING 


so  thai  they  do  not  interfere  with  the  work.  The  traps  for  these 
sinks  should  he  of  the  same  variety  as  used  for  other  sinks,  as 
described  under  traps. 

Kitchen  Fixtures.  In  Pig.  L37  are  shown  model  kitchen 
departments  with  all  necessary  fixtures  and  equipment  for 
such  rooms.  The  plumbing  fixtures  should  consist  of  sinks  for 
washing  pots  and  pans,  sinks  for  washing  vegetables,  and  butler's 
pantry  sinks.  A  sink  should  be  placed  in  the  baking  room,  also 
one  in  the  special  diet  kitchen.  In  the  illustration  the  ordinary 
diet  kitchen  is  shown,  and  the  only  fixture  in  this  is  a  sink  with 
ample  drain  hoard  space  (Fig.  137).  The  ordinary  diet  kitchen 
is  shown  in  Fig.  138. 

Sinks. — The   kitchen    sink    is    nrohahlv    the   fixture  which   re- 


no.  139. 

ceives  the  hardest  wear  of  all  those  in  a  hospital.  The  washing 
of  pots  and  pans  is  exceedingly  hard  on  the  surface  of  these  sinks. 
They  can  be  made  of  enameled  iron,  porcelain  or  vitreous  ware, 
but  the  enameled  is  best  adapted  for  this  rough  usage.  All  kitchen 
sinks  should  be  connected  to  a  grease  trap,  as  described  under 
traps,  and  should  he  supplied  with  hot  and  cold  water  through 
extension  faucets.  These  faucets  should  extend  over  the  sink  to 
about  eight  inches  from  the  hack  edge. 

Drain  hoards  for  kitchen  sinks  should  he  made  of  either 
enameled  iron  or  slaio.  which  can  he  covered  by  rubber  mats,  or 
they  should  he  made  of  well-seasoned  ash  with  an  enameled  joint. 
These  hoard-  should  he  bolted  and  made  especially  for  this  pur- 
pose. 


PLUMBING 


253 


Vegetable  Sinks. — Vegetable  sinks  should  be  of  the  pattern 
as  shown  in  Fig.  139,  having  three  compartments,  the  central  on  \ 
of  which  is  very  deep  and  used  for  washing  the  vegetables.    At  the 


/ 


FIG.  140. 

right  of  this  is  a  shallow  compartment   in  which  are  placed  the 

(-leaned    vegetables,    from    which    the    water   drain-    to    Hie    center 


254 


PLUM  15 1  x<; 


portion  through  the  grates.  To  the  left,  divided  from  the  center 
by  a  partition  somewhat  lower  than  the  edge  of  the  sink,  is  another 
compartment.  The  water  from  the  center  portion  .lows  over 
this  partition  and  drains  out  through  a  standing  waste.  The 
water  from  the  center  portion  is  drained  out  through  a  plug 
strainer  after  parings  have  been  removed. 

The  left-hand  section  is  also  used  for  the  washing  of  vege- 
tables. 

These  sinks  are  made  of  porcelain. 

Butler's  I\\xti;v  Srag_s. — Butler's  pantry  sinks  are  ordinarily 
made  of  planished  copper,  hut  are  also  made  in  all  porcelain,  as 
shown  in  Fig.  140.  In  the  latter  rubber  mats  should  be  used  on  the 
drain  boards,  and  a  wooden  mat  in  the  bottom  to  prevent  break- 
age.   In  the  copper  sink  the  howl  is  either  spun  in  oval  shape  or 


fig.  141. 

in  square  shape,  in  which  the  copper  is  blocked.  In  the  latter 
pattern  the  copper  is  placed  in  a  wooden  box  to  give  it  a  backing. 

The  drain  boards  are.  also  of  copper,  grooved  as  shown  in 
Fig.  141.  The  tops  can  also  be  made  of  marble  when  the  sinks  are 
copper.  A  full  countersinking  of  the  entire  slah.  with  proper  slope 
to  drain,  is  preferable  to  the  grooved  top. 

Supplies  for  pantry  sinks  are  ordinarily  Fuller  pantry  faucets 
as  shown.  The  waste  is  trapped  as  described  for  other  fixtures 
and  connected  to  the  waste  stack.  It  is  not  necessary  to  equip 
pantry  sink^  with  grease  traps.  ,-i>  only  glassware  and  silver  are 
ordinarily  washed  in  these  sinks.    If,  however,  the  dishes  are  all 


PLUMBIXt,  255 

washed  in  one  of  these  sinks,  it  must  he  equipped  with  a  grease 
trap.  The  square  pattern  is  fitted  with  a  slum  ling  waste,  and  the 
sink  itself  holds  the  body  of  water  for  washing  the  dishes.  En 
the  oval  pattern  a  plug  and  chain  are  used  instead  of  standing 
waste.  The  porcelain  sink  has  Fuller  faucets  as  shown  and  can 
be  equipped  with  standing  waste,  or  the  ordinary  strainer  waste, 
and  an  auxiliary  pan  used  in  the  sink. 

In  the  special  diet  kitchen  and  baking  room  an  ordinary  siok 
of  enameled  iron,  porcelain  or  vitreous  ware  should  be  installed, 
as  described  for  such  fixtures,  with  sufficient  drain  boards  for  each. 

Laundry  Tubs. — These  can  be  of  buff  porcelain,  stone  or 
enameled  iron.  In  the  individual  laundry  trays  in  bath  rooms  the 
tubs  should  correspond  to  the  remainder  of  the  fixtures,  and  should 
be  of  buff  or  white  porcelain  or  enameled  iron.  These  trays  are 
admirable  in  many  ways,  and  for  this  purpose  are  superior  to 
the  stone  trays,  as  they  are  integral,  while  the  stone  trays  are 
made  of  slabs  with  joints  cemented.  The  cocks  on  these  should 
be  of  the  turn  handle,  ground  key  pattern,  or  compression  cocks 
of  the  turn  handle  Fuller  pattern.  All  wash  trays  are  made  with 
and  without  backs,  but  for  hospital  purposes  the  integral  back 
tray  is  the  best.  Stone  trays  would  have  to  be  placed  at  a  dis- 
tance from  the  walls  sufficient  to  run  pipes,  while  in  the  tubs  of 
other  material  the  back  is  hollow  to  admit  of  these  pipes  and 
thus  set  close  to  the  wall. 

Tubs  for  the  laundry  can  be  of  any  of  the  materials  men- 
tioned, but  the  buff  porcelain,  enameled  iron  and  stone  trays  are 
best.  If  the  brass  boiling  pipe  described  under  laundry  equip- 
ment is  put  into  the  tub,  the  enameled  iron  or  stone  tub  would  be 
the  best  type  to  use. 

The  number  of  such  tubs  depends  upon  the  extent  of  the  re- 
mainder of  the  equipment.  Where  washing  machines  are  used. 
three  tubs  will  be  sufficient  in  all  instances.  These  tubs  can  be 
supplied  with  running  wastes  or  each  tub  can  be  equipped  with 
an  individual  waste.  The  running  waste  must  have  a  good  trap 
which  can  be  readily  cleaned,  placed  on  the  last  fixture  with  the 
running  waste  attached  to  the  trap  with  a  good  slope  toward  the 
first  tub.  The  ordinary  S  trap,  or  npn-siphon  trap,  will  be  suffi- 
cient in  case  individual  traps  are  used.  Running  wastes  and  traps 
can  be  made  of  galvanized  iron,  rough  brass  or  lead.  Nickel 
plated  brass  is  not  recommended  for  fixtures  in  laundries,  owing 
to  the  steam  and  dampness  in  such  places,  causing  corrosion  and 
the  constant  care  necessary  to  keep  the  nickel  plating  looking 
bright. 

Drinking  Fountains. — Drinking  fountains  arc  usually  placed 


256 


PLUMBING 


conveniently  in  t lit-  corridor  on  each  floor.  Supplies  for  drinking 
water  can  also  be  placed  in  the  main  kitchen  and  diet  kitchens, 
'nut  this  would  only  occur  in  larger  hospitals.  The  fountain  should 
1  rj  located  m  proximity  to  the  diet  kitchens.  These  fountains  are 
of  two  types — the  wall  fountain  and  the  pedestal  fountain.  The 
former  are  made  for  recessed  fountains,  as  shown  lb  Wig.  L42,  and 


FIG.    142. 

for  fountains  placed  directly  on  the  wall  (fig.  1  13).  These  foun- 
tains are  made  of  porcelain,  vitreous  ware,  enameled  iron  or  mar- 
ble. The  pedestal  forms  are  made  in  the  same  materials  and  vary 
in  design,  bul  are  all  of  the  general  type  shown  in  Pig.  144.  These 
fountains  are  equipped  with  a  cold  water  faucet  from  the  re- 
frigerator supply  and  a  waste  and  S  trap  as  shown.  The 
faucets  should  always  he  of  the  self-closing  pattern.  The  supply 
should  have  a  return  pipe  so  that  the  circulation  is  complete,  and 
so  that  cold  water  may  he  drawn  immediately  without  the  neces- 


PLUMBING 


257 


sity  of  wasting  the  water  which  has  been  standing  in  the  pipe 
Each  fountain  should  be  connected  to  this  return,  as  should  all 
other  fixtures  at  which  the  supply  of  drinking  water  is  drawn. 

Laboratory  Fixtures. — In  the  Laboratory  there  should  be  at 
least  one  sink  with  long  wooden  drain  hoards  on  both  ends.  It  is 
better  to  install  the  sink  in  the  working  table  in  such  a  position 
that  it  will  be  handy.  The  supplies  can  he  brouglri  up  at  the  rear, 
or  better  at  the  side,  if  the  table  is  accessible  from  both  sides  as 


FIG.  143. 

it  should  be.  The  filtered  hoi  and  cold  water,  as  well  as  the  house 
supply  hot  and  eoid  water,  should  he  broughl  to  this  fixture.  'I  he 
sink  should  be  of  enameled  iron  or  vitreous  ware  and  never  of 
porcelain,  as  the  enameled  iron  or  vitreous  ware  .-inks  an-  not 
affected  by  acids  or  stains,  while  the  porcelain  is  subjecl  t<«  Main 
ing  by  acids  and  dyes. 

In  the  laboratory  there  should  also  he  placed  a  slop  hopper. 
into  which  can  he  emptied  the  contents  of  specimen  jars,  and  such 
other  materials  as  are  ordinarily  used  in  the  laboratory.  Such 
solutions  should  never  he  emptied  into  the  sink,  as  they  will  quick- 
ly corrode  the  waste  and  trap,  which  are  made  ol   lead  or  brass, 


258 


I'M    M  him; 


while  the  trap-  for  the  slop  hoppers  are  part  of  the  fixture.  In 
the  hoppers  the  large  body  of  water  quickly  and  positively  car- 
ries away  the  solutions  on  account  of  the  long,  copious  Hush.  The 
waste  pipe  from  the  hopper  is  o!'  cast  iron  and  is  not  subject  to 
corrosion  as  easily  as  are  pipes  of  other  materials. 

In  the  laboratory  there  should  he  a  small  sink  supplied  with 
distilled  water  for  experimental  and  testing  purposes.  The  water 
may  come  from  a  small  individual  distilling  plant,  as  for  the 
operating  rooms  in  smaller  hospitals  where  no  large  general  plant 
or  storage  system  is  supplied,  or  if  the  hospital  has  but  one  small 
plant  in  the  operating  department,  water  can  be  supplied  in  bot- 


" 


FIG.  144. 

ties  to  the  Laboratory,  as  the  work  would  probably  not  be  of  such 
scope  ami  magnitude  as  to  require  a  greal  quantity. 

Eydbo-Thebapetjtics.  In  hydro-therapeutics  an  apparatus  is 
necessary  which  i>  not  installed  in  general  hospitals  ordinarily. 
This  apparatus  consists  of  C0n1  rol  tables,  needle  and  shower  baths, 
bidets,  baths,  scat  baths,  shampoo  tables,  weighing  scales  and  hath 
stools,  as  shown  in  Fig.  14.*). 


PLUMBING 


259 


--  303> 


-,  -  g  -  - 

2.  S.  »  3  3 

%  ^  n"  "^  -■ 

!*   -,  g   W  jq 

O  rt-    fB  ft 

5  ^    3  3 


?i  &»   EL  M  o 

ro  3   ^  5   5  p1 


H  c/>  <j  ^ 

mi 

S*  o  r1  a 


260 


I  LTJMBING 


The  Controlling  Table  is  arranged  with  mixing  chambers, 
eadh  with  a  temperature-regulating  valve,  pressure-regulating 
valve,  thermometer  gauge  and  electrical  alarm  for  indicating  high 
temperatures;  two  special  nozzles,  with  different  sized  tips  for 
pressure  streams.  Compression  valves  are  put  on  to  supply  hot, 
cold  and  ice  water  to  the  table,  and  also  to  control  the  water  to 
the  various  fixtures.  The  water  pressure  to  these  tables  must 
be  constant,  as  also  the  temperature  of  the  water.  To  obtain  con- 
stant pressure  it  is  customary  to  supply  water  to  the  table  from 
a  tank  or  reservoir,  located  at  a  sufficient  height  above  the  table 
to  give  the  maximum  pressure  which  will  ever  be  desired  for  treat- 


fig.  140. 

nient.  Constant  temperature  may  be  obtained  by  the  automatic 
controlling  device  explained.  The  pressure  controlling  device 
makes  it  possible  to  control  the  pressure  from  zero  to  the  maxi- 
mum. 

The  electrical  alarm  is  attached  to  each  mixing  chamber  and 
consists  of  ;i  special  thermometer  with  ;i  battery  and  bell,  so  ar- 
ranged that  when  the  temperature  of  the  watei  rises  to  a  point 
near  scalding,  the  hell  rings  automatically,  thus  giving  warning 
to  the  operator. 

Needle  and  Showeb  Baths.— These  are  arranged  with  four 
uprights,  upon  each  of  which  is  placed  a  number  of  rose  sprays, 
the  upper  on<-  adjustable,  and  also  a  large  head  spray  on  a  ball 
and  sockel  joint,  so  that  it  can  be  moved  in  all  directions. 


PLUMBING  26] 

Bidet. — This  is  a  small  nozzle,  swing  jointed,  which  is  usually 
attached  to  the  shower  or  to  a  water  closet  arranged  for  this. 

Bath  Tubs. — This  fixture  is  the  same  as  for  ordinary  tubs  and 
should  stand  free  as  described. 

Skat  Bath. — This  fixture  should  be  set  in  conjunction  with 
the  floor,  as  shown  in  Fig.  14(>,  and  can  be  of  enameled  iron  or 
porcelain.  The  fixtures  should  be  wasted  as  described  for  ordi- 
nary bath  tubs. 

Shampoo  Tables. — These  tables  are  made  oi  enameled  iron, 
marble,  glass  and  also  of  porcelain,  mounted  on  wrought  iron 
standards  or  frames  which  are  enameled.  Over  (Ms  table  is 
placed  a  shampoo  spray,  which,  it'  it  is  not  controlled  from  the 
controlling  table,  should  be  equipped  with  a  non-scalding  device 
or  valve. 

Bath  Stool. — This  is  made  of  wood  covered  with  celluloid 
enamel  with  an  opening  in  the  center,  to  be  used  in  connection 
with  the  perineal  douche. 

Resume. — In  conclusion,  the  entire  system  of  sewerage,  sup- 
ply and  installation  of  fixtures  should  be  generous  in  size  and 
simple  in  installation  and  operation.  All  pipes  in  supplies  should 
be  generously  valved,  each  valve  marked  by  brass  lags,  giving 
the  location  of  fixtures  on  each  main  and  each  branch,  or  should 
have  a  numbered  tag  and  a  chart  conveniently  placed.  There 
should  be  uniformity  in  all  piping,  so  that  corresponding  pipe- 
have  the  same  relative  location.  All  risers  .should  have  besides 
the  valves  mentioned  a  check  valve,  so  as  to  avoid  hack  pressure, 
and  in  cross  connection  should  have  gate  and  check  put  on.  Each 
supply  at  each  fixture  should  also  be  properly  valved,  so  that  any 
supply  at  any  fixture  may  he  closed  off  without  interfering  with 
any  other  supply.  In  this  manner  the  whole  system,  any  part  of 
the  system,  any  set  of  fixtures,  any  fixture,  or  any  supply  on  such 
a  fixture  can  be  closed,  and  the  water  turned  off  without  inter- 
ference with  any  other  part  of  the  system  or  fixture  respectively. 
Directness  and  simplicity  of  system  are  the  first  essentials  in 
plumbing  requirements. 

GAS  FITTING. 

Gas. — (Jas  in  hospitals  is  installed  for  two  purposes— illum- 
ination and  fuel.  Under  illumination  the  methods  for  lighting  by 
gas  are  fully  explained. 

Piping. — The  method  of  piping  the  building  depends  wholly 
upon  the  construction  of  the  hospital.  In  ordinary  construction 
the  pipes  are  laid  over  the  rough  floor,  before  the  deafening  is  put 
in,  and  are  also  placed  in  the  partitions,     in  fireproof  construction 


262 


PLUMBING 


the  pipes  are  laid  in  slots  left  for  them,  or  more  frequently  are 
laid  on  the  tile  or  concrete,  and  the  deafening  put  in  over  them  if 
wooden  floors  are  laid,  or  bedded  in  the  cement,  when  such  floors 
are  finished  in  materials  other  than  wood.  In  the  latter  case  the 
cinder  concrete  must  not  be  permitted  to  come  in  contact  with 
the  pipes,  as  the  latter  frequently  disintegrate  when  in  contact 
with  this  material.  All  pipes  laid  in  floors  deafened  with  cinders 
must  be  protected,  before  the  deafening  is  applied,  by  a  coating  of 
neat  cement. 

From  the  meters  to  ail  outlets  the  piping  should  he  properly 
proportioned  so  that  the  system  is  positive  and  noiseless.  As  in 
water  supplies,  it  is  host  to  run  pipes  from  manifolds,  or  to  take 
the  supply  for  each  floor  from  a  main  riser  which  is  placed  in  the 
pipe  and  wire  way  provided.  The  system  in  mains  and  branches 
must  be  proportioned  so  thai  there  will  he  no  diminution  in  any 
lights  when  other  lights,  or  all  lights  on  a  floor,  are  turned  on. 
There  should  be  a  shut-off  at  a  point  outside  the  meter,  and  also 
one  on  each  floor  for  the  entire  floor,  so  that  the  gas  on  any  floor 
may  he  turned  off  wiihout  interfering  with  the  lights  on  any  other 
floor. 

Supply.  The  lap  for  gas  Iron;  the  street  main  into  the  build- 
ing is  usually  put  in  by  the  municipality  or  the  local  company  sup- 
plying the  gas,  and  carried  into  the  building  where  the  meter  is 
placed.  Prom  the  meter  the  main  riser  or  manifold  is  taken  and 
from  this  the  several  branches  are  derived.  The  running  of  these 
branches  depends  wholly  upon  the  location  of  fixtures  and  the 
number  of  lights  on  each  fixture. 

Size  op  Piping. — In  hospitals  the  minimum  size  of  gas  mains 
and  branches  is  calculated  on  the  number  of  outlets,  the  length  of. 
the  tubing,  and  the  inside  diameter  of  the  latter. 

M  \.\  [JFACTURED   GAS    FOE    LIGHT. 


Size  of  tubing. 

(ireates!     length      al- 
lowed. 

Greatest    number    of 
1  ')  inch  openings. 

1  ••  inch    

;  •  |   inch    

20  feel 
GO  feel 

7<»    feet 

LOO  feet 
150  feel 
200  feet 

1    opening 
8   openings 
12   openings 
20   openings 
35    openings 
50   openings 

1       inch   

i  i  |   inch   

2       inch    

pig.  147. 


PLUMBING 
BUILDING    SERVICES. 


263 


Size  of  opening. 


1      inch 

1  i  |  inch 
iy2  inch 

2  inch 


Greatesl    number    of 
Greatesi     length    al-j     %     \ur\i    openings 


lowed. 


711  feel 

LOO  feet 

150  feet 

200  feet 


allowed. 


1   opening 
3   openings 
.')  openii  gs 
S   openings 


FIG.  148. 
All  openings  in  service  should  be  equal  to  the  size  of  the  riser, 
which  in  no  case  must  be  less  than  three-quarters  inch. 

MANUFACTURED    GAS   FOR   FUEL. 


Size  of  tubing. 


%  inch 

1  inch 

I14  inch 
iy2  inch 

2  inch 


Greatest    length     al- 
lowed. 


50  feet 
70  feet 

100  feet 

150  feet 

200  feet 


Greatest  number  of 
s/4  inch  openings 
allowed. 


1-%-in.     or    2-1  L.-iii. 
2   or   ]-'■'•  1  -ill.   and   2- 

1  ..-in. 
4  or  2-"'  |-in.  and  4- 

1  ..-in. 
7   or  4-:;  rin.   and   6- 

i/2-in. 
1,")  or  8-3  ,-in.  and  14- 

1  ..-in. 


fig.  149. 
natural  gas  foe  fuel. 


Size  of  Greatesl 

openings,  length. 
Inches.     Feet. 
1 ._,  21 1 

2»> 


1 ., 
3i 


Classification  of  appliances. 

Small  portable  gas  cooking  stove 

Kitchen  boiler  heater  when  separated  from  range. 
Miscellaneous  appliances  consuming  less  than   15  cu 

ft.  per  hour  each 

Gas  cooking  ranges    

Ordinary  coal  ranges,  equipped  for  the  use  of  gas.  :; , 

Miscellaneous  appliances  consuming   L5   to  40  en.   It. 

of  gas  per  hour  each "1 

Miscellaneous  appliances  consuming  4»>  to  7.~>  cu.   It. 

of  gas  per  hour   

Pipes. pipes  for  gas  should  he  of  wroughl  iron  with  all  'it- 
tings  under  two  inches  of  malleable  iron,  connections  between 
pipes  being  made  by  couplings,  the  pipes  being  screwed  into  these. 


20 
30 
30 

30 

<;o 


264  PLUMBING 

All  connections  between  pipes  and  fittings  should  be  made  by 
screwing  together  with  linseed  oil.  The  openings  should  all  be 
capped  with  iron  caps,  screwed  on,  and  the  whole  system  tested 
by  air  pressure. 

Tests.-  In  testing  a  pump  is  used,  and  the  pipes  forced  full 
of  air  to  sustain  a  mercury  column  at  least  six  inches  high.  This 
column  is  in  a  graduated  glass  gauge,  and  must  remain  stationary 
for  at  least  twenty-four  hours.  This  test  should  be  applied  before 
any  pipes  are  concealed  either  by  plastering  or  before  floors  are 
laid  over  the  pipes.  The  caps  should  be  left  on  until  the  fixtures 
are  hung.  No  split  pipes  or  joints  made  with  cement  or  lead 
should  be  put  into  the  building.  The  piping  should  be  laid  with 
a  fall  toward  the  meter  or  the  main  riser,  as  the  ease  may  be, 
and  should  be  well  secured  with  hooks  and  bends. 

Nipples. — The  nipples  should  be  of  the  exact  length  for  hang- 
ing the  fixtures  to  them  without  alteration,  as  any  cutting  on  ac- 
count of  excessive  length,  or  the  placing  of  additional  nipples 
might  cause  disturbance  of  the  pipes  sufficient  to  produce  a  leak 
in  the  walls  or  floors.  These  nipples  should  be  exactly  perpen- 
dicular to  the  ceiling,  or  at  right  angles  in  all  directions  to  the 
walls  from  which  they  project. 

Fuel  (i.\s. — Fuel  gas  should  be  run  separately  from  illuminat- 
ing gas,  and  should  be  entirely  independent  of  the  latter.  It 
should  have  its  own  meter  and  stop  cocks.  Fuel  gas  is  run  in  the 
same  manner  as  illuminating  gas,  the  size  of  the  pipe  depending 
upon  the  requirements  as  given  in  the  tables.  The  piping  should 
be  done  in  the  same  manner  as  for  illuminating  gas,  either  from 
a  manifold  or  from  a.  main  riser,  and  the  supply  on  each  floor 
should  be  independent  of  the  supply  for  all  other  floors,  with  a 
shutoff  on  each  respectively. 

Outlets. — The  piping  should  he  run  direct  for  the  main 
kitchen,  baking  room,  special  diet  kitchen,  and  for  sterilizing  ap- 
paratus. Besides  the  cock  for  shutting  oil"  the  supply  to  the 
burner1-  of  such  fixtures,  there  should  be  a  stop  cock  on  the  supply 
pipe  to  shut  oil"  the  gas  from  the  entire  fixture,  and  one  to  shut 
off  the  gas  from  each  group  of  fixtures.  Diet  kitchens  should  be 
equipped  with  fuel  gas  for  stoves  and  also  with  a  cock  for  hose 
connection  for  a   Bunsen  flame  burner. 

The  number  of  outlets  and  their  location  in  the  pathological 
laboratory  depend  upon  the  extent  of  this  department  and  it- 
equipment.  Pipes  for  Bunson  burners  should  run  exposed  at  the 
rear  i'd^^  of  work  benches  with  a  sufficient  number  of  taps.  Each 
run  should  ho  controlled  by  a  separate  shutoff.  as  well  as  each 
individual  burner  plug.     There  should  also  be  a  general   shutoff 


PLUMBING  265 

for  the  entire  laboratory  so  that  t lie  supply  of  gas  can  be  turned 
off  from  this  room  without  interference  with  any  other  part  of 
the  hospital.  Provision  should  also  be  made  in  this  room  for 
the  supplying  of  special  apparatus  with  sufficient  burners  for  this 
portion  of  the  equipment.  There  should  be  several  swing  fixtures 
arranged  for  blow-pipe  work. 

The  placing  of  separate  shutofrs  on  each  group,  and  on  each 
run  and  fixture  of  such  groups  throughout  the  building  cannot  be 
too  strongly  advocated.  A  slight  leak  in  a  pipe  under  such  cir- 
cumstances does  not  necessitate  the  shutting  off  of  the  entire  gas 
supply  in  the  building,  as  is  the  case  when  these  cocks  are  omitted 
and  repairs  are  necessary.  Moreover,  one  part  of  a  group  can  be 
shut  off  in  any  room  without  interfering  with  the  remainder  of 
the  work  in  that  room.  This  is  especially  true  of  hospitals  which 
are  entirely  dependent  on  gas  for  illumination  and  for  fuel. 


CHAPTER  XV. 

PLASTERING. 

There  are  more  methods  in  the  lathing  and  plastering  of 
buildings  than  there  arc  systems  of  building,  because  there  is  the 
possibility  of  applying  the  methods  in  many  forms.  As  an  ex- 
ample, in  non-fireprooi'  buildings  ordinary  wooden  lath  and  plaster 
can  be  used,  or  the  wood  lath  and  cement  plaster  can  be  put  on. 
Wire  lath  and  plaster,  or  expanded  metal  and  plaster,  are  used  in 
buildings  so  constructed.  There  are  methods  in  which  plaster 
board  is  used  and  merely  a  finishing  coat  put  on  this.  Built  up 
hollow  blocks  are  sometimes  used  instead  of  studs  and  lath,  ami 
these  plastered  with  a  skim  and  finishing  coat. 

In  fireproof  buildings  plastering  of  partition.-  depends  upon 
their  method  of  erection.  As  mentioned  in  Fireproonng,  there 
arc  a  multitude  of  these,  and  the  plastering  would  depend  upon 


the  form  of  construction.  In  fireproof  buildings  the  inside  of  out- 
side  walls,  as  well  as  inside  brick  walls,  can  be  done  in  several 
ways.  It  is  evident,  therefore,  thai  to  describe  all  would  not  be 
expedient-  Such  as  are  ordinarily  used  will  be  considered,  and 
the  general  outline  for  the  plastering  will  be  given  to  cover  all 
possible  and  ordinary  cases. 

Lathing. — In  non-fireproof  buildings  this  can  be  done  with 
wood,  wire  or  expanded  metal  put  directly  on  the  studs  and  ceiling 
joists.     The  following  points  are  to  be  observed: 

If  wood  lath  are  used,  the  besl  seasoned  and  sound  first  qual- 
ity pine  lath  should  be  procured,  one-quarter  inch  thick  having 
no  bark  on  them.  They  should  be  placed  a  full  quarter  inch  apart 
and  be  nailed  four  times  in  the  length  of  the  lath,  as  shown  in 
Pig.  ioii.    At  a  distance  of  eighteen  inches  over  all  the  areas  lathed 


PLASTERING 


267 


joints  should  be  broken,  as  shown  in  Fig.  151.  There  must  be  no 
long  vertical  joints,  nor  must  lath  be  put  on  vertically  nor  run 
through  angles  behind  partitions  from  one  room  to  another.  The 
lathing  in  each  room  must  he  independent. 

Expanded  Metal. —  In  lathing  with  expanded  metal  on  wood 
studs  care  must  be  taken  that  the  Lath  is  placed  so  that  the  mortar 
will  key  properly.  There  is  a  top  and  bottom  to  this  material 
which  is  recognizable  by  the  fact  that  the  key  should  form  as 
shown  in  Fig.  152.  Fig.  153  shows  the  method  of  putting  this  on 
wooden  studs. 

Metal  Lath. — Metal  lath  on  metal  studs  arc  hung  over  the 
"clips"  on  the  channel  irons,  as  shown  in  Pig.  154,  and  the  clips 
are  bent  back  to  securely  hold  the  lath  in  place.  This  is  the  besl 
form  of  construction  of  the  methods  described.     It  is  rigid,  inde- 

i_j Ju U Ll 


2 


± 


z 


z 


— f 


— ■" 


FIG.  151. 

structible  and  absolutely  fireproof,  besides  being  practically  a  unit 
for  each  , »;i  rt  ition  when  complete. 

Tile  Partitions. — When  tile  partitions  are  put  into  build- 
ings and  the  inside  of  outside  walls  and  inside  brick  wails  have 
been  furred,  the  following  is  the  method  recommended.  Where 
two-coat  work  is  specified,  three-coal  work  can  he  used,  hut  with 
hard  and  cement  plasters  if  has  been  found  thai  the  two  coal  work 
will  fulfill  all  requirements.  All  slots,  iron  beams  ami  other  iron 
work  where  exposed,  ami  all  splays  where  these  are  formed,  ex- 
cept in  brick  walls,  are  to  be  covered  with  expanded  metal  lath. 
Wherever  there  is  a  corner,  a  corner  head  should  he  placed  se- 


2G8 


PLASTERING 


curdy,  as  shown  in  Figs.  4A  to  48,  50  and  51.  These  beads  should 
also  be  put  on  at  all  other  corners  which  protrude  (  Figs.  155,  156, 
1.57). 


WBONG 


PIGHT 


FIG.  152. 

Plastering. — In  making  mortar  for  plastering,  it  is  absolute- 
ly essential  that  the  ingredients  be  given  time  to  thoroughly  mix. 


m{ 


FLOOR 


; 


FIG.  153. 

The  brown  coat,  or,  as  it  is  sometimes  designated,  the  brown 
mortar  hair  coat,  is  made  of  fresh  quick  lime,  coarse,  sharp  sand 
free  from  loam,  and  for  each  barrel  of  the  lime  a  bushel  of  good, 


PLASTERING 


269 


sound  plastering  hair  should  be  used.  The  lime  must  be  well 
slacked.  This  musl  be  done  thoroughly,  for  ii  ls  this  that  makes 
the  difference  between  good  and  bad  plaster.     Plaster  which  has 


f  ' 
i 


i 
i 


-t 


lL 


I  I 


1 


FIG.  154. 

the  lime  improperly  tempered,  pops,  cracks,  scales  and  develops 
all  the  evils  to  which  plaster  is  subject.    After  the  lime  is  slacked 


fig.  L54A. 

it  should  be  screened  to  remove  any  foreign  matter.  The  sand 
and  hair  should  then  be  added,  mixed,  and  the  whole  mp,ss  lefl  to 
stand  for  at  least  ten  days  before  being  used. 


270 


PLAF  i'i. i;i  \o 


Eard  Plaster. — When  the  ready  mixed,  hard-wall  plasters 
and  cemenl  plasters  arc  used,  instead  of  the  ordinary  mortar 
plaster,  all  that  is  needed  is  the  addition  of  water  to  these  in  the 
mortar  box  and  their  application  to  the  surfaces.  At  times  a 
plaster  of  Pari--  putt>  is  mixed  into  these  to  prevent  too  rapid 
setting,  as  all  of  these  so-called  patent  plasters  dry  out  much 
(juicker  than  common  plaster.  They  are  somewhat  more  expen- 
sive in  firsl  cost,  hut  are  far  superior,  if  of  good  quality,  to  the 
hest  mortar  plaster.  They  finish  with  an  extremely  hard  surface, 
and  the  bond  between  the  coats  is  as  much  a  chemical  as  a  me- 
chanical "clinch,"  if  they  are  put  on  in  the  proper  manner.     The 


FIG.   155. 

saving  of  time  alone  more  than  compensates  for  their  little  ad- 
vance cost,  and  in  wear  and  tear  of  the  material  they  are  a  good 
investment.  Decorations  are  not  subject  to  stains  in  them  as  in 
lime  mortars  when  such  staining  is  due  to  the  plaster. 

Plastering  is  done  in  one-coat,  two-coat   and  three-COat   work: 

One-Coat  Work.     In  dumb-waiter  shafts,  pent  houses,  walls 

and  ceilings  of  basement,  except  where  there  is  no  plastering  nec- 

essary,  one  heavy  coat  of  hard  plaster  should  he  applied,  and  this 

troweled  down  perfectly  plumb,  straight  and  smooth. 

Two-Coat  Work.  Two-coal  work  is  applied  to  nil  walls,  par- 
titions and  ceilings,  except  where  one  and  three-coat  work  are 
put  on.     The  firsl   coat,  known  as  the  brown  coat,  is  put  on  and 


I'LASTKKIXO 


27] 


troweled  down  perfectly  plumb  and  straight,  and  before  this  is 
set,  or  hardens,  it  is  scratched  with  a  piece  of  wire  mesh;  over 
this  is  put  the  finishing  coat.  Care  must  be  taken  that  the  brown 
coat  is  wet  before  the  latter  is  applied.  The  finishing  coat  is  put 
on  and  carefully  ganged — that  is,  made  level  and  true  throughout 
its  length  and  height  on  walls  and  level  on  ceilings.  This  is  trow- 
eled down  to  a  smooth,  glossy  surface  with -a  trowel  and  brush, 
care  being  taken  that  no  brush  marks  show.  All  angles  snould  be 
sharp  and  true,  plumb  and  straight,  as  the  case  may  be. 

If  lime  mortar  is  used,  a  finishing  coat  is  put  on  made  of 
stucco  and  lime,  the  former  being  made  of  plaster  of  Paris  in  pro- 


fig.  156. 
portions  to  secure  a  good  and  well-finished  wall.  This  coal  should 
be  well  gauged  and  brought  to  a  smooth  and  glossy  surface,  show- 
ing no  brush  marks.  When  using  Lime  mortar  for  plastering  every 
precaution  should  be  taken  to  prevent  stains  through  Lnsumcienl 
tempering.  This  may  be  done  by  mixing  into  the  putty  coat,  or 
white  hard  coat  finish,  a  fixed  quantity  of  chemicals  made  for  this 
purpose.  This  has  also  the  tendency  to  give  a  higher  degree  of 
hardness  to  the  white  finish  when  it  is  dry  than  it  would  other- 
wise have. 

Three-Coat  Work . — Three-coat  work  should  he  done  on  all 


272 


PLASTERING    i 


surfaces  lathed  with  expanded  metal  lath.    The  first  coat  is  desig- 
nated as  "scratch"  coat.     It   is  a   rough  coat,  heavily  scratched. 


FIG.  157. 

and  serves  the  purpose  of  forming  the  "keys'7  which  hold  the 
plaster  to  the  metal  (Fig.  158).  Over  this  is  placed  a  browning 
coat,  as  described,  and  then  finished  with  the  finishing  .coat. 


FIG.  158. 

Openings.— All  openings  Tor  ventilating  registers  and  thim- 
bles for  pipes  should  be  carefully  considered  and  the  plastering 
brought  to  these  in  a  neat  manner.     This  also  applies  where  the 


PLASTERING 


plaster  runs  to  molds  to  form  splays,  -ills  and  jambs  I  Figs.  47  and 
51).  Where  no  trim  is  to  be  used  and  corners  are  rounded,  this 
should  be  done  carefully  so  as  to  get  true  surfaces  plumb  and 
straight.    If  coves  are  formed  at  the  ceiling  these  should  be  "run" 


fig.  159. 

in  forms,  made  of  metal,  and  should  be  gauged— namely,  made 
true  on  their  entire  length  with  trowels  shaped  for  this  purpose. 
Coves  are  ordinarily  run  solid,  as  shown  in  Fig.  159,  but  they  can 
be  formed  by  expanded  metal,  as  shown  in  Fig.  160.  While  coves 
at  the  ceiling  may  be  considered  as  an  ornamental  feature,  they 
are  not  a  necessity,  for  the  accumulation  of  dust  in  the  angle 
formed  by  a  wall  and  (he  ceiling  is  slight.  Where  pressure  sys- 
tems of  ventilation  are  used,  coves  might  be  advantageous,  bul 
even  under  these  circumstances  they  can  be  emitted.  They  are 
expensive  luxuries  at  best. 

It  might  be  mentioned  here  that  when  hard  plaster  is  used 
a  very  successful  and  inexpensive  floor  cove  can  be  formed  when 
the  wall  plaster  is  put  on.  as  shown  in  Pig.  L61.  In  doing  this,  ii 
will  be  necessary  to  put  down  either  a  metal  or  wood  ground 
which  is  permanent,  so  that  the  cove  is  not  broken  when  the  floor 
is  laid. 

Covers. — It  is  often  necessary,  ami  a  good  precaution  at  all 
times,  to  have  the  window  openings  in  the  entire  building  covered 
with  canvas  or  cheesecloth  to  exclude  dusl  and  dirt,  and  to  prevent 
cracking  of  the  plaster  on  account   of  air  currents.     The  windows 


274 


PLASTER]  \'o 


should  never  be  tightly  closed  with  glass,  if  possible,  for  the  plas- 
ter dries  too  slowly,  except  in  freezing  weather,  if  all  air  is  ex- 


FIG.  160. 

eluded.     In  freezing  weather  this  precaution  is  necessary,  but  the 
windows  should  be  left  partly  open  top  and  bottom,  so  as  to  expe- 


fi<; 


;    L61. 


dite  the  evaporation  of  the  moisture  in  the  plaster.     Too  quick 
drying  is  to  be  avoided,  as  it  causes  cheeks  and  cracks. 


CHAPTER  XVI. 


PAINTING. 

There  is  no  part  in  the  construction  of  hospital.-  which  per- 
mits of  such  latitude  of  treatment  as  the  interior  painting  and 
decorating,  especially  where  it  would  seem  thai  a  recognized 
standard  should  be  followed.  At  first  glance  there  seems  little 
need  to  give  the  subject  much  scrutiny,  but  this  is  not  the  case. 
Precedent,  moreover,  is  not  necessarily  a  standard,  for  this  has 
often  been  the  guide  for  the  improper  treatment  of  walls  and 
woodwork.  Because  white  enamel,  for  example  is  good  material 
to  use  in  operating  rooms,  it  does  not  follow  that  ii  is  the  best, 
nor  even  the  proper,  material  to  use  in  other  parts  of  the  building. 
Especially  is  this  true  of  closets,  for  reasons  which  will  he  given 
later. 

Under  the  heading  of  paints,  enamels  and  varnishes  will  be 
given  an  analysis  of  what  constitutes  good  material,  their  proper 
application,  the  best  methods  to  he  employed,  and  the  place  in 
which  each  is  to  be  used  to  the  best  advantage 

Paints. — In  general  the  use  of  paints  for  walls  and  interior 
decoration  is  constantly  growing.  These  are  much  cleaner  and 
more  healthful  than  wallpaper  or  tinting.  They  dry  with  an  egg 
shell  finish,  in  light  ami  pleasing  shades,  and  can  he  very  har- 
moniously arranged.  They  can  he  cleaned  at  any  time  with  little 
trouble  with  warm  water  ami  soap  and  rubbed  with  a  flannel  doth. 

In  finishing  walls  in  these  interior  colors,  the  besl  manner 
of  procedure  is  to  give  the  walls  one  coat  v\'  best  quality  ready 
mixed  paints,  and  after  this  is  thoroughly  dry  put  on  a  coat  of 
"size."  This  latter  is  pure  boiled  linseed  oil  equally  reduced  with 
turpentine.  The  turpentine  is  used  to  thin  the  oil  so  that  the 
plaster  will  absorb  it.  Upon  this  base  is  put  one  or  two  coats  of 
paint,  according  to  the  finish  desired.  The  last  coat  should  be 
stippled.  This  is  done  with  a  stippling  brush,  and  consists  in 
going  over  lightly  the  lasl  coat  before  it  is  dry,  by  striking  the 
bristles  of  the  brush  against  the  surface  upon  which  the  naini 
has  been  applied. 

The  object   in   putting  the  "size"  between  the  coat-  i-  thai 
should  any  objed    hit    the  wall,  instead  el'  the  white  plaster  show- 


276  PAINTING 

ing  and  making  unsightly  spots,  it  would  chip  oft'  the  coats  over, 
jiikI  the  under  coat  would  remain  and  still  show  the  same  color  as 
the  paint,  it  being  on  the  plaster  itself  underneath  the  size. 

Attention  is  directed  under  plastering  to  the  special  treatment 
of  plaster  walls.  It  will  be  necessary  in  many  instances  to  treat 
the  walls  in  the  manner  described  to  prevent  stains  on  the  paint, 
the  lime  in  the  mortar  not  being  sufficiently  tempered,  on  account 
of  its  use  too  soon  after  mixing.  When  the  plaster  is  not  suffi- 
ciently tempered  it  attacks  the  lead  in  the  paint.  It  is  often 
necessary  when  this  occurs  to  scrape  the  entire  surface  of  the 
walls  and  ceiling,  and  remove  both  paint  and  much  of  the  hard 
coat  of  plaster,  and  then  to  treat  such  scraped  surfaces  with  com- 
pounds. In  some  instances  it  is  even  necessary  to  put  canvas  on 
after  the  plaster  is  scraped  smoothly.    This  canvas  is  then  painted. 

Undue  haste  should  not  be  permitted  here,  for  it  is  the  cause 
of  more  expense  and  worry  than  the  matter  of  a  few  days'  delay 
really  warrants.  As  stated  in  the  chapter  on  Plastering,  no  work 
of  this  character  should  be  done  until  the  lime  is  perfectly  tem- 
pered. In  some  instances  in  which  good  work  has  been  required, 
plaster  has  been  mixed  fully  a  year  in  advance  of  its  use,  merely 
to  overcome  any  subsequent  delays,  and  the  possibility  of  ruin- 
ing decorations.  While  this  is  not  necessary  under  ordinary  condi- 
tions, it  is  an  indication  that  care  bestowed  at  the  outset  prevents 
direful  consequences  which  inevitably  follow  undue  haste. 

Enamels. — There  are  many  so-called  enamels  on  the  market 
that  extreme  caution  must  be  exercised  in  the  choice  of  these,  and 
also  in  their  application.  Particular  attention  is  directed  to  ma- 
terials of  this  character  which  retain  their  elasticity.  No  enamel 
which  contains  lead  should  be  used,  as  it  deteriorates  quickly, 
turns  yellow  and  cracks.  Only  such  are  safe  to  use  as  are  abso- 
lutely guaranteed  not  to  crack  and  which  hold  their  whiteness  or 
color  indefinitely.  It  is  well  to  look  thoroughly  into  this  subject, 
as  it  is  the  means  of  saving  time  and  money  and  the  annoyance 
of   refinishing. 

In  finishing  plaster  walls  with  enamel  no  special  preparation 
of  such  work  is  necessary,  Tor  materials  of  this  kind  can  now  be 
obtained  which  are  guaranteed  to  withstand  all  staining  from 
plaster,  if  the  enamel  is  applied  after  the  plaster  is  thoroughly 
dry.  This  last  precaution  is  absolutely  requisite,  however,  for 
the  successful  treatment  of  walls  and  ceilings  in  this  manner. 
Enamel,  above  all  other  material,  is  recommended  for  the  treat- 
ment of  sin-faces  to  he  decorated.  Such  surfaces  are  easily  cleaned 
and  absolutely  sanitary,  and  the  enamel  is  easily  applied.  The 
application  is  as  follows : 


PAINTING  '_',  < 

New  Walls. — In  enameling  new  or  unpainted  plaster  walls 
four  coats  should  be  used.  The  first  coat  to  be  Lead  and  oil,  about 
one  quart  of  boiled  linseed  oil  to  the  gallon,  the  remainder  to  be 
pure  turpentine.  The  second  coat  should  be  a  perfectly  flat  coat 
namely,  lead  and  turpentine,  with  only  the  minimum  of  oil,  not 
over  half  a  pint  to  the  gallon.  The  third  and  fourth  coats  should 
be  good  flowing  coats  of  enamel  as  taken  from  the  can.  The  third 
coat  must  stand  24  to  36  hours  before  the  fourth  is  applied. 

Plaster  Walls  or  Wood  work  Previously  Painted-— The  old 
paint  should  be  thoroughly  cleaned,  and,  it  white,  washed  down 
with  strong  soda  and  warm  water.  The  first  '-oat  should  he  a 
perfectly  flat  one  of  lead  and  oil — namely,  lead  and  turpentine, 
with  only  the  minimum  of  oil,  not  over  hall'  a  pint  to  the  gallon. 
The  second  coat  should  be  a  good  flowing  one  of  enamel  taken 
from  the  can. 

Interior  Woodwork  of  Close  Grained  Wood. — All  woodwork 
should  be  thoroughly  sand  papered  with  fine  sand  paper.  All 
knots  should  be  shellaced  to  prevent  the  sap  from  coming  en;. 
This  is  called  "killing."  The  first  coat  on  the  wood  should  he  lea, I 
ami  oil.  with  about  one  quart  of  boiled  linseed  oil  to  the  gallon, 
the  remainder  to  be  pure  turpentine.  The  second  coat  should  lie 
a  perfectly  flat  one  of  filler  or  lead  and  turpentine,  with  only  the 
minimum  of  oil,  not  over  half  a  pint  to  the  gallon.  This  should 
then  be  rubbed  down  with  fine  sand  paper  to  remove  any  prom- 
inent brush  marks.  The  third  coat  should  he  a  good  flowing  coai 
of  enamel  as  taken  from  the  can.  After  the  third  coat  has  stood 
for  24-  or  36  hours,  it  should  he  rubbed  down  with  sand  paper, 
or  pumice  and  water,  just  enough  to  cut  the  id<>ss.  and  then  a 
fourth  coat  of  enamel  applied. 

Open  Grainkd  Woodwork.—  A  good  hardwood  filler  should  he 
well  nibbed  into  the  surface;  after  this  is  dry  and  hard  the  work 
should  be  sand  papered  Lightly,  and  a  thin  coat  of  shelhic  applied. 
The  first  coat  over  this  is  the  usual   lead  and  oil.  the  same  as  for 

other  work.     The  other  thr< oats  to  he  applied   the  same  as 

for  close  grained  wood. 

Many   so-called   enamels  contain   a    large   percentage   of    lead, 
which  inevitably  oxidizes  under  the  action  of  lime,  antiseptic  fluids 
and  general  atmospheric  conditions,  thus  not  only  causing  discol 
oration,  but  cracking  and  scaling. 

Enamel,  no  matter  what  shade  is  \\<<^\.  even  if  it  he  pure 
white,  will  turn  darker  in  color  if  put  into  closets  and  other  dark 
places.  The  action  of  lighl  on  these,  as  well  as  on  paints,  i-  to 
cause  them  to  retain  their  color. 

When  we  refer  to  enamel   our  minds  immediately  conceive 


'278  i>.M  xi  i  n»;  ' 

white.  This,  however,  is  not  the  Limitation  of  color,  for  the  range 
is  without  limit  from  white  to  black.  All  shades  of  grays,  blues, 
greens,  reds,  yellows,  and,  in  fact,  the  same  multiplicity  of  shades 
as  in  paints,  are  obtainable  in  enamels.    There  are  primarily  two 

classes  of  these — the  flat  and  gloss.  By  the  mixture  of  these  in 
the  same  shade,  or  even  different  shades,  any  desired  gloss  can 
he  obtained,  the  result  being  quite  artistic. 

Varnish-  Another  source  of  annoyance  in  hospitals,  as  well 
as  in  other  buildings,  is  the  deterioration  of  the  varnish,  ('racks 
and  checks  appear,  the  varnish  turns  white  or  blisters  or 
"sweats."  This  latter  is  due,  however,  to  improper  application 
oftener  than  to  inferiority  of  material.  It  causes  the  unsightly 
spots  which  look  like  oil  stains  and  which  are  so  evident  in  their 
discoloration.  When  a  coat  of  varnish  is  applied  before  the  pre- 
ceding  coat  is  thoroughly  dry,  the  result  is  usually  this  "sweat- 
ing." 

For  the  besl  ami  most  desirable  results  when-  varnish  finish 
is  desired  on  the  woodwork,  the  use  of  three  coats  of  varnish  is 
recommended.  The  first  coat  applied  directly  to  the  wood,  thinned 
by  about  ten  per  cent  of  pure  turpentine.  This  should  be  sand 
papered  smooth  after  it  is  thoroughly  dry  and  hard,  and  followed 
with  two  coats  of  regular  body  varnish  without  thinning.  Is  stat- 
ed, sufficient  time  must  be  allowed  between  the  coats  to  permit 
each  to  harden  thoroughly.  Liquid  fillers  and  shellac  should 
never  be  put  on  the  wood  under  varnish,  as  it  does  not  make  a 
durable  job.  These  cause  the  varnish  to  easily  scuff  oif,  or  the 
varnish  turns  white  on  the  filler  and  shellac.  This  is  especially 
true  of  window  sills  and  woodwork  exposed  to  the  weather.  If 
the  metal-clad  trim  were  used  throughout,  as  mentioned  in  the 
chapter  on  Carpentry,  this  method  would  not  apply,  as  such  trim 
i-  painted  and  grained  to  look  like  wood,  and  is  then  varnished  in 
the  same  manner  as  in  woodwork. 

Floors,  where  of  wood  (and  it  is  evident  that  these  are  never 
10  be  of  open  grained  wood,  but- preferably  of  maple,  which  is 
close  grained),  shouio  b<  given  ;i  coal  of  floor  varnish  thinned  by 
about  ten  per  cent,  pure  turpentine.  They  are  then  sand  papered 
smooth  ;n.<i  given  two  good  coat-  of  varnish.  The  same  objection 
v.  the  use  of  shellac  and  filler,  as  stated  in  connection  with  trim, 
applies  to  floors  also,  with  the  addition  thai  the  varnish,  besides 
scuffing  off.   shows    heel    marks   when   applied   over   these. 

Taken  in  the  order  in  which  they  are  mentioned  herein,  the 
treatment  of  rooms  and  surfaces  with  these  materials  respectively 
IS  as   follows  : 

Paint   and  enamel,   being  interchangeable,  as   may   seem   best 


•;7<) 
PAINTING  -'• 


to  those  in  charge— although  enamel  is  recommended— no  separate 

mention  need  be  made  for  general  conditions. 

The  walls  and  ceilings  of  wards  and  rooms,  corridors,  offices, 
consultation  and  waiting  rooms,  and  such  administration   rooms 
as  exist,  should  be  treated  as  stated,  in  colors  to  suil   the  rooms 
in  which  they  are  used,  if  such  a  standard  can  be  established,  or 
to  suit  the  taste  of  those  who  have  this  in  charge.     Enamels   in 
.ooms  and  wards  arc  undoubtedly  to  be  preferred— thp^ofjhe 
flat  varietv  being  the  best,  as  there  is  no  reflection  of  Lighl  which 
is  so  trying  on  the  eyes  of  the  patients.    White  is  not  a  good  I  reat- 
ment,  for  the  reason  that  it  gives  a  cold  appearance  to  the  room 
or  ward     Soft  gray  or  buff  and  delicate  green  tones  for  the  walls 
of  wards  are  admirable.    Forjhe^orridors  these  colors  also  may 
be~u7ed,  hnt  the  i^oTTlnd  buff  tones  are  much  to  be  preferred 
as  they  are  warm  in  effect  and  make  the  corridors  bright   and 
cheerful.     The  rooms  and  corridors  of  upper  rooms  where  there 
is  plenty  of  light  can  be  somewhat  darker  in  tone,  white  enamel 
being  added  on  each  floor  from  the  top  down  as  the  light  dimin- 
ishes, until  on  the  ground  floor  the  enamel  is  several  shades  Lighter 
than  that  above.     The  walls  can  be  treated  in  one  color  and  tne 
ceilings  in  another,  or  the  walls  in  a  darker  tone,  and  the  ceilings 
in  light  tones  of  the  same  color. 

No  gloss  enamels  should  be  used_  except  in  operating,  ster- 
ilizing, toilet,  hath,  dressing  and  anesthetizing  rooms,  Kitchen 
and  diet  kitchens  should  also  be  treated  in  gloss  finish.  These 
Should  be  done  in  white  gloss,  including  the  woodwork.  \  arnish 
'  can  be  used  on  the  trim,  but  it  is  not  as  good  as  the  enamel,  as 
the  latter  is  more  elastic  and  is  not  affected  by  antiseptic  solu- 
tions Flat  enamels  soil  much  more  easily  than  gloss  enamels, 
but  by  mixing  these  a  slight  gloss  can  be  obtained.  However, 
the  soiling  of  walls  is  of  no  great  consequence,  as  the  enamel  is  so 
easily  cleaned,  and  this  must  be  frequently  done  for  hygienic 
reasons.  In  hospitals  ordinarily  the  occupants  of  sum  rooms  are 
not  about  enough  to  soil  the  surfaces. 

The  question  of  finishing  walls  of  operating  rooms  has  aever 
been  definitely  settled.  The  methods  of  treating  such  walls  are 
fully  explained  elsewhere.  It  seems,  however,  after  much  thought 
and' investigation  on  the  subject  of  such  rooms,  that  walls,  ceiling 
and  trim  of  any  of  the  various  materials,  named  arc  ao  better  than 
those  which  are  carefully  enameled.  Enameled  surfaces  arc  as 
easy  to  keep  clean  and  arc  as  aseptic  and  serve  their  purpose  a1 
a  much  lower  cost.  They  can  be  renewed  yearly  with  bn1  little 
expense  and  arc  always  while  and  sightly.  The  enamel  never 
cracks,  if  it  is  of  the  right  kind,  and  retains  its  whiteness  mdeh- 


L'SO  PAINTING 

nitely.     There  is  only  one  precaution  necessary — the  walls  must 
be  thoroughly  dry  held  re  the  enamel  is  applied. 

Varnishes  should  be  on  all  trim  and  on  wooden  floors,  except 
in  the  rooms  in  which  enamel  is  used  as  stated  above. 

In  general  these  conditions  should  be  followed:  All  wood- 
work should  be  clean  before  finish  is  applied;  all  knots  and  resin- 
ous spots  where  paint  is  applied  to  woodwork  should  be  shellaced, 
using  grain  alcohol  shellac.  Wood  alcohol  should  never  be  used 
iu  good  work. 

Outside  Painting. — Three  coats  of  paint  should  be  used  on 
all  outside  work,  including  tin.  iron  and  other  metal.  The  first 
coat  of  paint  on  all  metal  work,  however,  should  be  either  graphite 
or  one  of  the  mastic  paints  now  in  use  on  bridge  work;  and  which 
are  not  affected  by  fumes.  Red  lead  is  extensively  used  for  first 
coat  on  metal,  but  this  is  not  the  best  manner  of  treating  such  sur- 
faces, as  it  docs  not  protect  the  metal  sufficiently.  All  nail  holes, 
also  ail  cracks  and  imperfections,  if  any  occur  after  the  priming 
or  first  coat  is  applied,  should  be  tilled  with  putty. 

[nside  Painting-  Painting  of  walls  is  not  ordinarily  consid- 
ered a  part  of  the  inside  painting,  but  more  properly  as  part  of 
the  decorating,  except  the  enamel  work.  The  same  rules  hold  as 
for  outside  painting.  The  varnished  surfaces  must  have  all  nail 
holes  puttied  with  putty,  colored  to  match  the  wood  after  the  first 
coat  is  put  on. 

Staining.— The  matter  of  staining  woods  to  any  desired  color 
must  necessarily  be  left  to  those  in  charge.  Very  artistic  and 
beautiful  effects  can  be  obtained  in  this  manner.  In  the  private 
rooms  this  could  be  done  to  advantage  and  the  furniture  finished 
to  match.  This,  while  it  may  be  purely  the  esthetic  viewpoint, 
might  be  advanced  as  an  argument  in  favor  of  making  our  hos- 
pital- homelike.  This  would  give  to  the  occupants  of  such  rooms 
surroundings  to  which  they  are  ordinarily  accustomed.  It  entails 
no  additional  cost  to  do  this,  and  helps  considerably  in  making 
hospitals  more  attractive.  Wards  should  be  finished  in  light  color, 
preferably  the  natural  colors  of  the  wood. 

Other  Methods. — When  the  walls  are  finished  with  hard  plas- 
ter or  cement  plaster,  they  may  be  treated  with  a  cement  coating. 
a  substance  resembling  calcimine.  This  material  has  been  suc- 
cessfully used  under  the  above  conditions  and  very  pleasing  effects 
obtained  at  small  cost.  As  a  matter  of  economy  in  the  first  in- 
stance, and  in  order  to  permit  the  wails  to  dry  out  thoroughly, 
these  substances  can  be  used.  They  are  made  especially  for  ce- 
ment, plaster  and  stucco  surfaces.  They  are  not  cold  water  paints 
and  contain  no  glue  or  other  substances  subject  to  deterioration, 


PAINTING  281 

but  are  oil  paints  without  white  lead,  and  can  be  cleaned  and 
washed  the  same  as  any  lead  and  oil  paint.  They  do  not  rub, 
crack  or  peel.  Their  great  advantage  lies  in  the  fact  that  they  can 
be  applied  to  a  damp  surface  where  it  is  impossible  to  make  paint 
and  enamel  stay.  One  coat  is  often  sufficient  for  ordinary  pur- 
poses. They  need  not  be  removed  when  permanent  decoration  is 
done,  as  they  act  as  a  base  or  filler. 

It  seems  that  this  might  be  good  practice,  inasmuch  as  it 
serves  a  double  purpose,  and  it  must  be  evident  that  economy  at 
the  outset  along  these  lines  is  to  be  commended.  The  'drying 
out  of  the  walls  cannot  be  too  well  done,'  and  anything  which  will 
facilitate  this  is  to  be  recommended.  In  many  instances  the  plas- 
tering is  completed  well  in  advance  of  the  occupancy  of  the  build- 
ing, so  that  sufficient  time  has  elapsed  for  thorough  drying.  How- 
ever, in  the  usual  rush  of  our  modern  methods  this  is  not  always 
the  case,  nor  is  it  expedient  to  have  it  so.  As  has  been  stated, 
delays  are  costly,  and  when  the  same  results  can  be  obtained  by  a 
little  delay  in  the  final  decorating  without  additional  cost,  it  is  the 
proper  course  to  follow.  By  drying  out  of  walls  is  not  meant  the 
evaporation  of  quantities  of  water  into  the  room,  but  rather  the 
final  setting  of  the  plaster,  which  is  always  attended  somewhat  by 
very  slight  moisture. 

Calcimine.— The  same  results  would  undoubtedly  be  obtained 
by  using  calcimine  or  cold  water  paints.  They  have  the  disad- 
vantage, however,  of  having  to  be  renewed  frequently,  as  they 
cannot  be  cleaned  as  can  paints  and  enamels.  The  ordinary  tint- 
ing, so  called,  consists  in  calcimining  the  walls  and  ceilings.  This 
is  done  by  "preparing"  the  surfaces  to  be  treated  with  hard  oil 
and  over  this  applying  the  calcimine. 


CHAPTER  XVII. 

ELECTRIC  WORK. 

LJnder  the  head  of  Lighting  are  fully  described  the  differenl 
methods  of  hospital  illumination.  In  this  chapter  the  entire  sub- 
ject is  treated  from  the  point  of  construction,  and  such  devices 
as  arc  necessary  for  the  several  systems  will  be  given  only  in  those 
forms  as  will  he  necessary  for  their  proper  installation.  The  sub- 
ject of  electric  wiring  for  power,  illumination  and  for  the  many 
other  purposes  is  too  comprehensive  to  he  treated  fully  in  a  chap- 
ter of  this  character.  There  are  separate  treatises  on  each  and 
all  of  these  subjects.  Power  plants,  moreover,  could  not  he  stand- 
ardized in  their  installation,  as  they  depend  wholly  upon  condi- 
tions, the  results  desired  and  the  size  of  such  installations.  The 
installation  of  the  necessary' wiring  for  lighting  by  electricity, 
whether  it  he  in  the  use  of  incandescent  lights  or  of  the  other 
forms  <>!'  lighting  described  under  Illumination,  is  primarily  the 
same  for  all  cases.  It  is  only  necessary  to  ascertain  the  number  of 
lights,  the  amount  of  power,  whether  for  running  motors  or  spe- 
cial apparatus,  and  proportion  the  feeds,  mains  and  branches  ac- 
cordingly. 

Each  municipality  has  i1s  own  rules  and  regulations  govern- 
ing the  wiring  of  buildings,  and  each  local  company  also  has  its 
requirements  for  such  work;  added  to  these  is  also  the  National 
Board  of  Underwriters'  code,  which  must  be  complied  with,  if 
the  rate  for  insuring  the  building  is  to  be  kept  at  a  minimum, 

Systems  of  Wiring. — There  are  two  systems  of  wiring  a  build- 
ing for  electric  Lighting— viz.,  the  two  and  three  wire  system.  The 
mains  are  usually  on  the  three-wire  system  if  the  supply  of  cur- 
renl  is  alternating,  ami  the  submains  on  the  two-wire  system. 
Branch  circuits  from  either  of  these  are  on  the  two-wire  system 
from  distributing  cut-outs.  Wiring  is  also  done  in  either  bush 
work  the  latter  either  scaled  or  open  work — and  the  former  rim 
in  conduits,  which  are  pipes  specially  made  for  this  purpose. 

The  open  system  need  not  he  explained  particularly,  as  the 
requirements  of  the  conduil  system  fully  cover  it. 

There  are  two  methods  of  running  the  conduit  system — one 
the  Laying  in  of  the  entire  system  of  piping,  and  the  pulling  in  of 
wires  from  outlet  to  outlet   in  branch  circuits;    or  the  installation 


ELECTRIC    WORK  -°'-> 

rf  pipes  already  wired,  which  come  in  long  lengths.    The. Init 

H     •  ,,  £orm  ,.„„„,  in  van,,,,  lengths,  and  ,s  pur.  together  with 

, dinary  screw  and  aipple,  in  the  same  manner  »  m  gas  pipe. 

The  objection  to  condnit  systems  of  this  kind  ,s  t  ha  m  tending 
the  pipes  from  one  outlet  to  another  the  pipe  is  flattened  at  th. 
bends,  and  makes  a  difficult  passage  for  the  wire  to  he  drawn 
„„,,„„.!,  u  is  recommended  that  some  of  the  flexible  condnits 
which  are  now  being  manufactured  and  made  water-taught,  be  used 
in  all  this  work.    They  are  mnch  more  economical  in  their  laying, 

although  their  first  cost  is  somewhat  in  advance  of  the  p »n- 

duit      They  haw  the  advantage,  moreover,  of  coming  m  great 
[engths  and  being  continuous  from  one  outlet  to  another  for  this 


n,i.  162. 
reason.     At  the  joints  of  the  pipe  conduit,  unless  these  are  care 

fully  reamed  and   -n thed,  there  are  rough   places  where  the 

wirL  are  liable  to  catch,  and  the  insulation  scraped  or     skinned 

from  the  wire,  making  it  possible  to  short-circuit  the  entire  system 

bv  contact  of  wire  and  tal.  .        . 

'     own  bt  Boxes.— Where  difficult  bends  are  required  m  the  sy» 

ten,  it  is  best  I it  in  an  outlet  box,  which  can  afterward,  be 

hermetically  sealed,  but  shoub ssible  at  all  times,  in ease* 

is  neCessary  to  redraw  the  wire  into  such  condnit  for  one  canse  01 

another.  ,      .  1    ,     1  .,,..1 

Pi«  162  shows  outlet  box.  These  are  made  ol  pressed  steel  and 

have  dies  punched  lightly  into  them  on  all  sides   so  that  a  blow 

from  a  hammer  will  drive  them  ont.    The  pipe ,1.  held  m  these ,  by 

means  of  a  lock  nnt,  and, ;hing  on  either  side  as  shown.     Ihes. 

are  threaded  or  screwed  on  the  end  of  the  pipe. 


284  ELECTRIC   WORK 

Wire. — Main  wires  within  the  building,  and  also  submains, 
are  -usually  cables  which  are  manufactured  and  which  come  in  un- 
broken lengths  and  arc  run  from  the  source  of  supply  to  the  cut- 
out box  or  distributing  panels,  as  the  case  may  be.  The  main  feed 
wire, "be  it  from  the  outside  source  or  private  plant,  should  run  to 
a  switch  cabinet  in  which  is  placed  the  service  switch  tor  the  build- 
ing. 

The  wire  used  in  the  building  must  he  amply  designed  tor  the 
load--  which  are  to  he  carried,  and  should  he  el'  the  besi  rubber- 
covered  type,  thoroughly  waterproofed.  The  mains  from  the 
service  to  the  cut-out  cabinets  should  he  provided  of  ample  carry- 
ing capacity  and  of  such  size  that  the  maximum  drop  in  their 
voltage  from  the  service  to  the  cut-out  cabinets  should  not  exceed 
two  per  cent.  The  wire  for  the  distributing  circuits,  which  run 
from  the  cut-out  cabinets  to  the  various  light  outlets,  should  not 
be  less  than  fourteen-gauge  copper  wire,  and  each  circuit  should 
have  no  more  than  twelve  lights.  For  circuits  more  than  one 
hundred  feet  in  length  the  wire  should  be  of  sufficient  size  so  that 
the  drop  in  potential  should  not  exceed  two  volts  at  the  full  load. 

The  wire  for  power,  >\u-\i  as  for  elevator  service  and  such 
other  electrically  driven  power,  as  laundry  machinery,,  pumps, 
etc..  and  for  X-ray  and  other  electrical  apparatus  of  like  character,, 
will  not  he  specially  mentioned,  as  these  must  he  left  entirely  to 
the  kind  of  power  which  is  to  be  supplied  and  the  number  of  volts 
accessary  tor  this  power.  The  usual  voltage  for  such  power  is 
far  in  excess  of  what  is  required  for  electric  light. 

Joints. — All  joints  in  wire  where  spliced,  or  where  branches 
are  taken  off,  and  all  connections  throughout  the  wer\  sliould  he 
thoroughly  soldered.  Wrapping  these  joints  with  tape  to  insulate 
them,  without  this  soldering,'is  neither  safe  nor  positive — that  is, 
there  might  he  a  flaw  in  the  connection,  and  a  consequent  disorder 
<>t'  the  entire  plant  dependent  upon  the  wire.  Moreover,  it  is  a 
point  at  which  an  electric  spark  might,  by  causing  fire,  do  consid- 
erable damage.  After  the  joints  are  soldered  they  should  he 
wrapped  with  rubber  tape  to  the  thickness  of  the  insulation  of  the 
original  wire,  and  the  whole  should  then  he  covered  with  a  fric- 
tion tape  extending  over  the  insulation,  and  on  both  sides  of  the 
joint,  to  make  a  firm  and  secure  hold.  All  wire  should  he  run 
from  outlet  to  outlet  in  unbroken  lengths-  that  is,  there  should 
be  no  joints  whatever  except  at  the  outlet  boxes. 

Cut-Outs. — Cut-out  cabinets  should  he  placed  on  each  of  the 
respective  floors  which  thev  are  to  serve.    The  feed  for  these  cut- 


ELECTRIC   WORK 


•>85 


outs  should  be  run  in  a  pipe  and  wire  slot  provided  for  the  pur- 
pose and  ordinarily  should  be  lead  protected.  The  cut-out  should 
be  in  the  same  position  in  each  hall  or  corridor,  so  that  there  is  a 
uniformity  which  makes  it  possible  for  quick  and  easy  access,  and 
so  that  the  main  feed  wire  can  be  run  with  as  few  submains  as 
possible.  Moreover,  these  cut-outs  should  be  put  in  the  wall  at  a 
convenient  height  so  that  they  are  easily  reached.  Arrangement 
should  be  made  for  the  cut-outs  when  the  building  is  erected,  by 
leaving  areas  in  the  wall,  so  that  the  doors  which  cover  these  boxes 
are  on  a  flush  surface  with  the  wall,  and  can  be  made  very  sightly 
as  well  as  convenient. 


fig.  163. 

Cabinet  panel — two-wire   mains. 

Carinets. — All  cabinets  must  he  designed  for  the  purpose  for 
which  they  are  intended,  as  there  may  ho  more  or  loss  variation 
in  the  omnber  of  cut-outs  and  switches  which  arc  to  be  put  mi<> 
these  cabinets.  There  arc  two  types  of  those — the  ordinary  steel 
box,  which  will  ho  explained,  and  that  in  which  .-.  wiring  compart 
ment  is  used.  The  former  is  illustrated  in  Fig.  1(i;;  and  the  latter 
in  I'ig.  1(54.  All  those  cabinets  should  bo  built  of  one-fourth  inch 
thick  steel,  their  corners  dovetailed,  substantially  reinforced  with 
corner  irons,  and  lined  throughout  with  one-fourth  inch  slate  or 


286 


ELECTRIC   WORK 


marble.  Conduits  should  terminate  in  these  cabinets  similarly  to 
conduil  boxes,  as  shown  in  Pig.  1(!_\  and  these  should  he  set  in  the 
wall  Hush,  as  mentioned,  and  be  provided  with  suitable  unit  or 
trim  and  door  frame.  The  doors  of  these  cabinets  must  close 
againsl  the  rabbet  or  groove  so  as  to  be  dust  tight,  and  should 
have  a  cupboard  door  catch,  and  if  necessary  a  lock  and  key. 

Distribution  Panels.— These  panels  are  placed  at  the  back 
of  the  cabinet  and  are  made  of  slate  or  marble  and  should  have 
suitable  main  and  branch  bus  bars  moulded  upon  them.  These 
bus  bars  are  (he  strips  of  copper  shown  in  the  illustration   (Figs. 


FIG.  164. 
Cabinet  panel  -three-wire   mains. 

lbo,  166),  and  are  now  used  in  almost  all  work  of  this  character. 
The  old  method  of  ''skinning"  the  wire  and  securing'  it  by  clamps 
at  each  fuse  block  is  neither  safe  nor  reliable.  In  the  bus  bar 
types,  of  which  there  are  several,  each  circuit  should  be  independ- 
ently controlled  by  a  secondary  switch,  besides  the  service  switch 
for  the  entire  floor,  so  that  one  circuit  can  be  out  of  service  without 
disturbing  the  remainder  of  the  circuits  while  necessary  repairs 
are  being  made  in  the  former. 

Fuses.— The  fuses  in  these  boxes  can  be  of  two  kinds— the 
ordinary    Edison   fuse  plug  which  screws   into  the   receptacle  and 


ELECTRIC  WORK 


287 


shown  in  Fig.  164,  and  the  inclosed  type  of  fuse  plug.  In  the  Latter 
there  are  spring  clips  set  at  proper  distances  to  receive  the  fer- 
rules which  are  set  on  each  end  of  the  fuses  and  connected  with 
the  fuse  inside  the  pasteboard  casing.  These  fuses  arc  made  in 
several  types,  but  the  principle  in  all  is  practically  the  same,  the 
object  being  to  prevent  any  arc  or  electric  spark  when  they  burn 
out.  They  should  be  of  ample  capacity,  but  should  be  no  heavier 
than  required  by  the  code.  The  plug  fuses  are  also  made  of  the 
inclosed  type. 

The  object  of  all  fuses  is  to  prevent  fire  or  accidents  if  the 


fig.  165. 

Two-wire    mains— double-branch    circuit-,   main   and    circuit    switches. 

voltage  becomes  too  high  in  the  wires  or  on  the  circuits,  the  fuses 
being  designed  to  burn  out  and  so  shut 'off  the  currenl  in  the 
particular  circuit  in  which  they  are  placed.  There  are  necessarily 
two  fuses  in  each  current,  one  on  each  wire. 

Switches. — Whether  the  currenl  for  power  worl?  is  from  pri- 
vate plant  or  from  outside  source,  there  should  he  placed  on  the 
main  feed  an  automatic  circuil  breaker  of  carrying  capacity  suffi- 
cient  at  all  times  to  automatically  control  this  currenl  (  Pig.  167). 
These  circuit  breakers  are  put  in  where  house  pumps,  elevators,  re 
frigeration  machinery  and  other  electric  power  is  used,  to  protect 
the  apparatus  against  overloads,  short  circuits,  underloads,  reverse 
currents  and    unbalancing   in    three-wire   systems.      On   the  main 


L'SS 


ELECTRIC   WORK 


feed  there  should  be  placed  a  service  cut-out,  This  cau  be  oue 
of  many  kinds,  often  a  combination  of  circuit  breaker  and  cur-out, 
but  under  all  circumstances  it  should  be  a  well-constructed  and 
positive-working  switch.  The  triple-pole  service  cut-out,  as  shown 
in  Figs.  168,  169,  is  espeeialh  for  large  installations.  It  is  so 
arranged  that  when  it  is  closed,  with  the  handle  in  its  normal  posi- 
tion, both  covers  are  locked  to  the  box.  In  case  of  emergency  a 
half  turn  of  the  handle  and  a  strong  pull  opens  the  complete  cut- 
out, the  blades  acting  as  a  triple-pole  switch.     The  main  service 


fig.  166. 

rhree-wire   main- — ihree-wire  double-branch   circuits,  main 


circuit    switches. 


switch  or  cut-out  should  always  be  placed  in  an  iron  box  and  at 
au  accessible  point,  so  that  in  case  of  fire  or  for  other  emergencies, 
it  becomes  imperative  to  shut  off  the  current,  it  can  be  done  read- 
ily. If  the  current  is  for  lighting  only  a  triple-pole  knife  switch 
cut-out  is  installed  in  a  convenient  place,  as  described  for  circuit 
breakers,  so  that  the  entire  current  can  be  shut  off  in  the  building 
in  case  of  necessity.  On  each  floor  there  should  be  placed  a  serv- 
ice switch,  so  that  the  entire  current  on  thai  floor  can  be  cut  out 
without  interfering  with  any  other  floor.    As  stated,  there  should 


ELECTRIC   WORK 


289 


be  n  small  switch  or  branch  switch  on  each  circuit,  so  that  an 
circuit  could  be  cut  out  without  interfering  with  any  other.     The 
auxiliary  switches,  and  branch  switches  should  all  be  placed  in  the 
same  cabinet,  as  shown  in  the  illustrations. 

All  chandelier  outlets  and  all  lights  at  the  ceiling  should  be 
controlled  by  separate  switches,  either  of  the  snap  or  turn  pat- 
tern, or  of  the  double  push  button  type.  Fig.  170  shows  the  snap 
switch,  and  Fig.  171  shows  the  push  button  type.  For  vapor  light- 
ing it  will  be  necessary  to  provide  knife  switches.  The  switches 
controlling  lights  should  be  selected  with  a  view  to  their  durability 
and  wearing  qualities,  as  well  as  to  their  perfection  in  working. 


fig.  167. 

There  are  many  so-called  electric  switches  to  be  obtained  which 
fail  to  operate  when  most  needed.  All  snap  and  push  button 
switches  should  be  set  in  steel  boxes  which  an-  made  especially 
for  the  purpose  (Fig.  172).  This  is  done  for  two  reasons  as  a 
protection  for  the  switch,  and  because  these  switch  boxes  are  put 
into  the  walls  and  partitions  before  the  walls  are  plastered.  It  is 
only  necessary  when  these  boxes  are  installed  to  put  the  switches 
into  place  and  fasten  them  to  the  lugs  made  for  the  purpose  after 
the  switches  are  properly  connected.  This  dees  away  with  the  driv- 
ing of  wooden  plugs,  which  are  very  insecure,  and  in  some  instances 
difficult  to  put  into  place.  The  boxes  should  be  set  plumb  and 
straight,  and  in  such  manner  that  the  mat  plate  over  the  switch 
sets  closely  against  the  wall. 


L'iKl 


ELECTRIC  WORK 


In  closets  where  there  are  Lights,  and  there  should  be  such 
Lights  in  all  closets,  two  kinds  of  switches  can  he  used — the  jamb 
.-witch,  which  turns  out  the  lii>iit  when  the  door  is  closed,  and  the 
snap  switch  with  an  "ofl  and  on"  indicator  (Fig.  L73).  The  latter 
should  also  he  used  throughout  such  working  parts  of  the  hospital 
when  the  Lights  which  are  switch  controlled  are  not  in  sighl   when 


FIG. 


168. 


FIG.  169. 


The  switch  is  turned— namely,  in  ice  boxes,  linen  and  Locker  rooms, 
>vhere  the  switch  is  usually  placed  outside  the  room.  In  closets, 
drop  cords,  with  key  sockets,  are  also  used,  and  in  some  instances 
this  method  has  its  advantages. 

Plugs. — Plugs  for  the  attachment  of  -portable  lights  or  for 
connecting  apparatus  should  be  generously  distributed.  There 
should  be  a  flush  receptacle  plug  at  the  head  of  each  bed  through- 
out the  rooms  and  wards.    These  should  be  uniform  s()  thai  any 


BLE<  Title    WoliK 


29J 


lamps  in  the  hospital  can  he  brought  into  and  used  in  any  room  or 
ward.  Under  Illumination  the  objects  of  such  lamps  arc  fully  ex- 
plained. These  pings  would  also  serve  lor  the  new  electric  wann- 
ing hags.  Receptacles  for  plugs  cither  of  the  flush  type  or  of  the 
type  to  receive  sockets  should  be  provided  lor  X-ray  apparatus  ai 


iji*.^awu'UM*  J-agynijBrew^Bij^ywww^w'y^ 


fixed  points,  as  also  in  the  X-ray  room.  In  the  latter,  however,  spe- 
cial panel  hoards  are  usually  installed.  In  the  diet  kitchens  there 
should  also  he  plug  receptacles  with  as  many  circuits  for  each  as 
will   he  found  necessary   for  any  cooking  or   heating  apparatus, 


FIG.   171. 

although  at  the  present  time  cooking  by  electricity  is  somewhal 
more  expensive  than  any  other  form.  Its  cleanliness,  rapidity 
and  ease  of  handling,  as  well  as  absence  of  odor,  are  so  evidenl 
that  it  no  doubt  will  eventually,  to  sonic  extent,  replace  oilier  forms 
of  heat' for  cooking  purposes  in  hospitals. 


292 


ELECTRIC  WORK 


Plugs  in  rooms  can  also  be  used  during  the  summer  months, 
when  the  temperature  is  high,  for  connecting  electric  fans  of  the 
small  household  type.  At  some  given  point  on  each  floor  the 
plugs  for  X-ray  apparatus  should  be  so  placed  as  to  give  access 
easily  to  rooms  where  such  treatment  is  necessary.  The  plugs  in 
the  diet  kitchen  could  also  be  used  for  this  purpose.    In  the  oper- 


ating rooms  there  should  be  plugs  for  such  apparatus  as  is  elec- 
trically  used,  such  as  galvano-cautery  and  apparatus  for  explora- 
tory work. 

Lights.— The   wiring  to  all   outlets   should  be  done  to  flush 
outlet  boxes,  so  adapted  that  the  fixtures  can  be  supported  from 


fig.  173. 

them.  In  operating  rooms,  if  swing  brackets  are  used,  the  outlet 
should  be  on  the  wall  in  such  position  that  the  connection  can  be 
made  as  it  would  be  for  an  ordinary  Avail  bracket. 

Circuits  should  be  so  arranged  that   lights  on  them  are  not 


ELECTKIC   WORK  293 

scattered — namely,  that  the  twelve  lights  on  any  circuit  should  not 
supply  corridors  and  sundry  rooms,  but  should  be  concentrated  as 
closely  as  possible.  Corridor  lights  should  be  run,  if  possible,  on 
alternate  circuits,  so  that  if  one  circuit  supplying-  the  corridor  is 
inoperative  for  some  reason,  alternate  lights  will  still  "be  burning 
in  such  corridors.  What  is  required,  if  possible,  is  an  independent 
outside  supply  for  such  corridors,  so  that  in  case  all  lights  went 
out  on  the  regular  supply,  the  corridor  lights  would  still  be  in 
service,  and  so  facilitate  the  travel  of  the  nurses  from  room  to 
room  to  light  the  gas. 

Signal  Systems. — Systems  for  signaling  from  rooms  and 
wards  are  of  two  kinds — the  annunciator  with  bell  and  drop  or 
needle  indicator,  and  the  more  modern  electric  signal  system.  The 
latter  is  rapidly  replacing  the  former,  owing  to  the  annoyance  of 
ringing  bells,  and  the  ease  with  which  the  annunciator  gets  out 
of  order  and  its  lack  of  positiveness  in  working.  There  is  another 
svstem,  a  combination  of  annunciator  and  electric  systems,  but 


fig.  174. 

there  is  the  same  objection  to  this  as  to  the  annunciator  with  bells 
and  batteries.  It  consists  of  an  inclosed  switch  worked  by  bat- 
tery, which  closes  an  electric  circuit,  and  so  indicates  by  light,  as 
does  the  electric  system.  The  necessity  for  a  battery  switch 
makes  the  connection  indirect,  and  so  is  subject  to  the  same  con- 
structional faults  as  the  annunciator  system. 

The  electric  signal  system  is  both  direct  and  positive,  as  only 
the  current  of  electricity,  which  is  used  for  lighting  piirposeSj  is 
necessary,  and  there  is  no  other  apparatus  needed  except  a  push 
or  pendant  switch  and  a  relay  for  the  pilot  lamp.  It  is  also  noise 
less.  This  system  is  as  follows:  At  the  head  of  each  bed  is  in- 
stalled a  flush  plug  receptacle  or  flush  outlet  for  a  flexible  cord. 
This  receptacle  is  placed  above  the  floor  cove,  and  a  flexible  electric 
light  cord  is  run  out  from  it,  upon  which  is  placed  a  pendant  push 
(Fig.  174).  The  two-button  protected  push  is  superior  to  the 
one-button  push  or  to  the  push  with  one  button  to  close  the  cir- 
cuit and  a  small   release  button  to  open  the  circuit.     Except   the 


294 


EL.ECTP.TC   WORK 


two-button  switch,  these  ali  break  when  they  fall  from  the  bed  to 
the  floor,  as  they  frequently  do.  These  pushes  when  operated 
light  an  electric  light  at  the  door  jamb  or  over  the  door.  This 
light  should  he  red,  as  the  white  light  during  daytime  is  not  read- 
ily seen,  and  at  night  the  Hashing  would  disturb  other  patients  by 


1m 


o 

L- 


reflection  through  transoms.  When  the  button  is  pushed  to  turn 
on  the  lighl  at  the  door,  a  light  called  the  pilot  is  turned  on  in 
tin-  diet  kitchen  or  nurses'  room.  This  latter  light  is  operated 
through  a  primary  coil,  as  shown  in  the  Fig.  175.    rl  his  light,  which 


■")"l 

ELECTRIC   WORK  -•''' 


is  placed  in  the  nurses'  room,  does  not  go  out  until  all  the  signal 
lights  on  the  floor  are  out.    Another  pilot  light  for  each  floor  can 
be  placed  in  the  superintendent  of  nurse's  room,  so  as  to  check 
each  floor  at  all  times.     These  pilots  in  the  head  nurse  a   room 
w.mld  he  placed  on  a  board  and  indicated  with  the  floor  number. 
The  floor  nurse  or  other  nurse  can  only  put  out  the  door  light  by 
going  into  the  room  and  turning  off  the  current  at   the  pendanl 
pnsh,  and  the  pilot  light  will  not  cease  burning  until  all  door  lights 
on  the  floor  have  been  extinguished.     For   wards,   an   auxiliary 
relay  or  primary  coil  could  be  put  in  so  that  all   patients   who 
called  from  one  room  would  have  to  be  given  attention,  and  the  cur- 
rent turned  off  from  all  buttons  pressed  before  the  door  light  would 
be  extinguished.    Such  a  system  should  be  separate  for  each  floor 
and  be  independent  of  all  other  lights.    Fig.  175  shows  the  wiring 
of  such  a  svstem,  and  also  the  primary  coil.    The  pilot  light  must 
be  put  into  the  circuit  before  all  other  lights.    When  a  light  at  a 
door  is  turned  on  by  pushing  the  switch  "A,"  the  current  mag 
netizes  "B"  as  it  is  passing  through  the  light  at  "L.         Llus 
mag-net  draws  up  the  lever  "C,"  which  forms  a  contact  with     D, 
and  in  this  manner  closes  the  circuit  to  the  pilot  light     J  .        *# 
long  as  a  light  is  in  operation  anywhere  on  the  floor  the  Penary 
eoil  is  magnetized  and  the  lever  "C"  is  in  contact  with  "D. 
Vs  soon  as  all  lights  are  out  there  can  be  no  more  current  flowing 
through  the  wires,  the  coil  no  longer  is  magnetized,  the  spring  m 
the  lever  releases  it  from  "D,"  and  the  pilot  is  extinguished. 

Another  system  which  has  been  used  successfully   to   some 
extent  is  designed  for  low  voltage  signaling.    It  has  as  its  greatest 
advantage  the  simplicity  of  its  installation.    It  is  only  necessary 
in  this  system  to  install  the  wiring  that  would  be  used  for  the 
ordinary  annunciator  system.     It  consists  of  an  armature  and  a 
magnet  so  arranged  that  when  the  circuit  is  closed  it  Is  Locked  and 
both  the  signal  and  pilot  lights  will  remain  burning  until  a   rod 
push  button  is  pressed  by  the  nurse.     The  signal  button  ,s  an  orch 
nary  pear-shaped  bell  push  on  a  flexible  cord,  wind,  is  oi    suffi 
Cient  length  to  be  brought  to  the  bed.     The  reset  button  IS  a  push 
on  the  wall  beside  the  bed  at  a  convenient  height.     Tins  reset  is  so 
made  tha1   ^to  it  can  be  plugged  the  locking  attachment.      I  his 
locking  attachment  is  the  part  of  the  apparatus  which  closes  the 
(Mlvuit    and   turns  on   the   signal   and   pilot    Lights.      The   object    ol 
plugging  the  locking  attachment  into  the  release  ls  to  facilitate 
the  quick  removal  of  the  former  if  it  .iocs  not  work   properly   for 
anv  reason,  and  putting  another  in  its  place  without  the  delay  o 
repairing  and  the  inconvenience  of  doing  this  a1  the  bedside.    All 
thai  is  necessary  is  to  have  on  hand  a  few  extra  attachments. 


296  ELECTRIC  WORK 

In  this  system  where  there  is  more  than  one  button  in  a  room, 
as  in  wards,  it  is  necessary  for  the  nurse  to  release  all  of  the  but- 
tons in  that  ward  which  had  been  pushed  before  the  signal  light 
is  extinguished,  and  ail  of  the  lights  on  the  entire  floor  must  be 
out  before  the  pilot  is  extinguished. 

The  entire  system  is  run  on  batteries  of  a  closed  circuit  type, 
oi-  of  the  storage  type,  and  will  operate  on  from  four  to  ten  volts. 
It  would  he  advisable,  however,  to  use  a  motor  generator  instead 
of  batteries,  and  while  this  is  running  through  the  day  it  could  be 
storing  a  set  of  batteries  to  which  the  entire  system  could  be 
switched  at  night,  and  the  generator  shut  down. 

The  signal  lamps  on  this  system  are  the  ordinary  miniature 
lamps.  In  the  nurses'  room  is  placed  an  annunciator  with  signal 
lamps  or  targets  indicating  the  room  or  ward  from  which  the  call 
is  sent.  An  auxiliary  annunciator  could  be  placed  in  the  Superin- 
tendent's  office  showing  all  the  rooms  and  wards  in  the  hospital 
as  described  above.  If  the  hospital  is  built  on  other  than  the 
straightaway  plan — namely,  those  of  U-shaped  plan,  in  which 
there  are  cross  corridors — there  can  be  more  than  one  station  for 
nurses,  and  in  such  a  case  there  would  be  an  annunciator  in  each 
nurse's  room.  Both  of  these  annunciators  would  be  so  arranged 
that  by  the  turning  of  a  switch  the  entire  signal  system  could  be 
switched  to  one  board  or  the  other,  so  that  a.ll  of  the  patient-  could 
be  taken  care  of  from  one  station  when  the  calls  are  but  few,  as  at 
night.  The  objection  to  this  i<  the  same  as  in  the  ordinary  annun- 
ciator system — namely,  that  the  more  or  less  delicate  and  intricate 
apparatus  is  liable  to  get  out  of  order. 

Bells. — The  number  of  bells  and  their  location  depend  wholly 
upon  the  wishes  of  the  authorities,  and  no  rules  can  be  set  down 
for  this  part  of  the  electric  work.  Under  any  circumstance  there 
should  he  a  push  at  the  main  entrance,  connecting  witli  a  bell  in 
the  nearest  room,  which  is  used  day  and  night.  This  would  prob- 
ably he  the  diet  kitchen  nearest  to  same.  Another  hell  connected  to 
the  front  door  push,  and  ringing  at  the  same  time  as  i  he  main  bell, 
should  lie  placed  in  the  matron's  or  the  Superintendent's  room, 
or  in  both,  with  a  small  cut-out  switch  on  each.  The  bells  should 
be  of  good  make  with  platinum  points,  and  should  have  a  sharp, 
full  ring,  hut  they  should  be  of  such  a  size  that  the  ringing  does 
not  disturb  patients  in  the  hospital,  as  all  such  hells  are  used  more 
frequently  at  night  when  the  doors  of  the  hospital  are  locked  than 
during  the  day. 

Batteries. — Batteries  for  those  bells  need  no  special  mention, 
as  they  can  be  of  the  sal-ammoniac  type  or  other  wet  cell  type,  or 
the  dry  cell  type.     The  latter  is  possibly  the  better  to  use,  as  it 


ELECTRIC  WORK  '-^' 


needs  no  attention  except  replacing  by  new  cells  when  the  old  ones 
rnn  down,  the  cost  of  these  being  very  small.  The  open  or  wet  cell 
needs  renewing  of  water,  adding  of  sal-ammoniac,  and  replacing  oi 
the  zinc  electrode.  In  the  use  of  the  dry  cells,  in  case  of  gradual 
weakening,  the  stronger  cells  will  reinforce  the  weaker  until  they 
are  all  run  down,  when  they  must  be  replaced  by  an  entirely  new 
set.    All  wire  for  electric  bells  and  battery  work  should  be  rubber 

covered. 

Telephones.— Instead  of  the  old  method  of  speaking  tubes, 
or  even  the  electric  bell  signal,  modern  hospitals  are  now  equipped 
with  intercommunicating  telephones.  These  often  lake  the  form 
of  extensions,  with  switchboard  of  the  outside  telephone.  Tins 
has  inanv  advantages,  but  a  private  telephone  system  serves  the 
purpose  as  well,  and  if  the  latter  can  be  made  to  connect  to  the 
outside  or  public  telephone,  it  has  all  the  advantages  of  the  ex- 
tension svstem.  In  the  private  telephone  system  the  entire  ap- 
paratus is  the  property  of  the  hospital,  and  can  be  controlled  by  it. 
whereas  in  the  public  telephone  system  restrictions  are  made 
which  are  often  onerous. 

Telephone   systems   of   the  extension   type   need   not    ho   ex- 
plained.    Those  of  the  private  type  are  known  as  the  central  en- 
ergy intercommunicating  telephone  system,  and  arc  so  arranged 
that  all  currents  for  signaling  and  for  transmission  are  furnished 
from  the  main  battery.    Each  station  in  this  system  should  be  so 
equipped  as  to  enable  connection  to  be  made  from  any  station  to 
anv  other  station  without  the  possibility  of  interference  from  an- 
other instrument,  and  which  will  permit  two  or  more  stations  to 
operate  at  one  time  without  interference  with  each   other.      1  he 
instruments  here  are  of  the  automatic  switch  and  plug  type,  op- 
erated on  two  general  plans— one  is  to  install  a  switchboard   at 
some  central  point,  at  which  all  the  telephone  lines  terminate,  and 
by  means  of  which  an  operator  can  connect  any  two  hues  together 
for  conversation.     Intercommunicating  systems  of  this  type  should 
be  used  where  there  are  more  than  twenty  stations.     For  twenty 
stations  or  less  intercommunicating  phon.es  of  the  individual  push 
or  individual  switch  or  ping  type  should  he  used.     In   these  the 
person  making  the  call  does  so  by  pushing  a  designated  button  or 
placing  a  plug  or  switch  on  the  proper  point  for  the  call  desired. 
In  the  selection  of  such  a  system,  and  the  instruments  therefor,  too 
much  stress  cannot  be  laid  upon  the  necessity  of  using  only  those 
which  are  of  approved  and  tested  merit.    Thee  are  systems  desig 
nated  merelv  to  meet  first  cosi  requirements,  vet  which  will  cosl 
more  than  a  good  svstem  in  repairs  aim.,-.    The  subjeel  ol   trans- 
mission of  orders  in  a  hospital  is  tar  too  important   In  permit   it 


298  ELECTSIC  WORK 

to  resl  on  the  expenditure  of  a  few  dollars  more  or  less,  as  the 
difference  in  cost  between  the  best  and  those  which  have  no  merit 
except  low  cost  is  surprisingly  small. 

Telephone  systems  should  be  equipped  with  a  superintend- 
ent's call  button,  which  is  a  button  on  the  main  office  telephone, 
which  rings  all  the  telephones  on  the  system  simultaneously.  This 
is  put  on  so  that  the  physicians  or  other  attendants  can  be  called 
to  the  telephone  by  a  designated  number  of  rings  on  the  floor,  or 
at  any  part  of  the  buildings  at  which  they  may  he  at  any  time. 

Wiring  fob  Telephones. — All  wiring  for  telephones,  whether 
large  or  small  installations,  should  he  done  in  metal  conduits  ter- 
minating in  steel  outlet  boxes.  The  boxes  should  be  so  set  and  of 
such  type  that  the  wall  telephones  can  be  fastened  to  them.  The 
wire  should  lie  in  cable  form,  and  he  run  in  unbroken  lengths  from 
outlet  box  to  outlet  box  where  telephones  are  to  be  placed,  and 
should  he  not  less  than  eighteen-gauge  copper,  rubber-covered  for 
battery  wire,  and  triple  braid  weatherproof  for  the  remaining 
lines.  All  wires  exposed  to  moisture  should  be  run  in  conduit  in 
lead-covered  cables. 

Batteries'.  The  batteries  depend  wholly  upon  the  extent  of 
the  telephone  system,  but  under  no  circumstances  should  the  bat- 
tery for  signaling  be  used  for  the  battery  for  talking.  Thev  must 
be  independent  and  of  a  capacity  for  the  proper  operation  of  the 
system. 

The  location  of  telephones  is  wholly  dependent  also  upon  the 
extent  of  the  installation  and  the  general  plan  of  the  hospital.  In 
the  office  and  superintendent's  room  there  should  be  desk  instru- 
ments. For  the  diet  kitchens,  main  kitchens,  engine  or  boiler 
room,  and  operating  department,  telephones  of  the  wail  type  are 
more  adaptable.  If  the  system  consists  of  over  twenty  phones, 
the  switchboard  should  he  conveniently  Located  in  the  office  or  at 
a  point  where  one  of  the  working  force  of  the  institution  can  read- 
ily answer  all  calls.  In  very  large  installations  a  switchboard 
operator  will  be  necessary. 

Power.— Wiring  ami  apparatus  for  power  depend  wholly  upon 
the  extent  of  such  i  nst  a  I  la  t  i  01 1  s.  In  hospitals  it  is  not  recom- 
mended to  run  line  shaftings,  as  these  at  best  are  not  as  quiet  in 
operation  as  the  individual  motor.  Each  piece  of  equipment  and 
each  elevator  or  pump  should  be  run  by  an  individual  motor. 
either  direct  connected,  which  is  the  preferable  form,  or  geared  or 
belted.  This  individual  drive  has  the  great  advantage  of  econ- 
omy, as  the  motor  is  onlj  operated,  and  the  power  used,  when  the 
individual  piece  of  apparatus  to  which  it  is  attached  is  in  opera- 
tion,    in  the  system  where  one  motor  and  line  shaftings  are  used, 


ELECTRIC   WORK  — '•' 


it  is  necessarv  to  operate  the  motor  at  all  times,  and  in  this  man- 
ner the  consumption  of  current  is  a  maximum,  whether  all  ap- 
paratus is  in  operation  or  whether  only  the  smallest  unit  is  id 
operation  Installations  must  be  figured  for  each  particular  case, 
as  no  standard  can  be  given,  but  should  have  a  good  percentage 
of  excess  power  so  as  to  be  quiet  and  positive  in  operation 


CHAPTER  XVIII. 


VENTILATION  AND  HEATING. 

VENTILATION. 

In  treating  this  subject  only  such  methods  arc  mentioned  as 
will  fully -explain  the  most  effective  systems.  No  ventilating  work 
can  be  complete  without  specific  knowledge  of  the  principles  in- 
volved; what  ventilating  means,  what  its  objects  are  and  how 
these  may  be  obtained. 

Both  the  Heating  and  Ventilating  sections  are  given  as  fully 
as  possible  in  a  chapter  of  this  character,  but  are  not  intended  to 
fill  the  requirements  of  specific  cases.  These  must  be  left  to  the 
expert.  We  are  indebted  for  much  valuable  information  to  Mr. 
S.  Homer  Woodbridge,  of  Boston,  whose  exhaustive  study  in  this 
line  is  well  known. 

In  discussing  the  relation  of  air  to  vital  energy,  we  are 
plainly  dealing  with  one  of  the  most  important  of  the  basal  truths 
of  man's  relation  to,  and  dependence  on,  the  sources  of  energy 
which  arc  placed  for  his  appropriation  and  use  in  the  carbon  of 
food  and  in  the  oxygen  of  air. 

The  fundamental  truth  or  law  on  which  the  demand  for  ven- 
tilation is  based  is  this:  Though  Nature's  resources  and  opera- 
tions are  vast,  her  methods  and  requirements  are  neither  coarse 
nor  haphazard  nor  approximate,  but  exact;  precise  to  the  ex- 
treme. The  aii-  as  it  exists  in  the  open  is  perfectly  and  exactly 
adapted  to  man's  vitality  and  to  his  industry.  Increase  the  pro- 
portion of  oxygen,  and  his  vitality  exhausts  itself  in  its  intensity. 
Decrease  the  proportion  of  oxygen,  and  vitality  droops,  languish- 
ing in  the  dullness  of  iis  unsupported  fires. 

The  aii-  as  it  is.  and  exactly  as  it  is,  in  the  open,  is  meant  also 
for  vegetation,  as  vegetation  by  nature  is  created  and  sustained. 

Abundance  and,  therefore,  purity  of  air  is  of  more  importance 
to  the  boiler  furnace  than  is  quality  of  fuel.  With  a  poor  draft 
the  mosl  successful  and  faithful  fireman  can  do  little,  even  with 
the  besl  of  coal.  With  a  good  draft  he  can  make  ami  keep  a  hot 
fire  with  poor  coal.  So  also  for  vital  fires  purity  of  air  is  more 
essential  than  is  purity  of  food.     The  one  is  created  ami  provided 


VKXTILV  HON     VXD   HEATIX(. 


301 


without  human  instrumentality;    and  environed   in  it   man  con- 
tinuously lives,  and  of  it  he  as  continuously  breathes. 

Food,  made  or  provided  through  human  instrumentality,  is 
partaken  of  only  at  intervals.  However  viewed,  as  to  origin,  as 
to  continuance  of  use,  as  to  importance  of  purity,  air  ranks  above 
food  in  vital  importance. 

Ventilating  work,  when  intelligently   planned  and   faithfully 
performed,  takes  due  cognizance   of  the  foregoing  fundamental 
truths  and  principles;    and  of  the  laws  of  nature  on  which  that 
work  must  be  based  if  it  is  to  be  correct  in  application  and  effective 
in  results.     It  regards  the  hospital  as  the  retreat  of  vitality  de- 
pleted through  the  shock  of  accident  or  the  waste  of  disease,  and, 
therefore,  the  place  of  all  others  where  the  physical  condition  of 
the  subject  demands  the  fullest  purity  of  vitalizing  air.     Further- 
more, the  time  of  duration  of  exposure  to  conditions  maintained 
in  the  hospital  is  long,  compared  with  that  of  exposure  to  the  air 
of  theaters,  lecture  or  music  halls,  or  churches,   public  convey- 
ances, land  or  sea.     Temporarily,  for  longer  or  shorter  periods, 
the  hospital  is  as  continuously  occupied  as  is  the  dwelling  house, 
and  more  so  than  the  office  or  school  building.    The  two  consider! 
tions,  therefore,  of  the  state  of  susceptibility  of  body  and  also  of 
the  time  of  duration  of  exposure,  conspire  in  the  demand  for  a 
more  free  ventilation  of  hospitals  than  of  any  other  class  of  build- 
ings for  human  occupation. 

In  surgical  wards  are  those  reduced  by  the  shock  of  opera- 
tion, augmented,  it  may  be,  by  that  of  accident.  In  the  air  may 
float  pus  microbes.  In  these  instances  is  enfeebled  vitality  on  the 
one  hand,  but  less  danger  in  the  quality  of  the  contents  of  the  air 
on  the  other.  Floating  dust  is  less  microbic,  or  the  microbic  form 
is  less  dangerous  in  character  in  the  general  than  in  a  contagious 
ward.  The  air  supply  may,  therefore,  be  reasonably  reduced 
from  the  quantity  appropriate  to  the  contagious  wards. 

The  physical  condition  in  the  general,  or  medical  wards,  is 
marked  by  vitality  depression  and  the  atmospheric  conditio!]  by  an 
absence  of  moribific  quality.  A  lower  per  capita  air-supply  is, 
therefore,  admissible  than  for  either  the  contagious  or  surgical 

wards. 

What  shall,  or  perhaps  we  may  more  safely  ask,  what  should 
be  the  gauge  of  air  supply  to  these  several  parts  of  the  hospital? 

No  ail1  can  be  too  pure  for  the  need  and  use  of  the  great  virile 
vitality,  certainly  not   for  impaired  vitality.     Lf  atmospheric  im- 
purity is  to  be  maintained  at  a  minimum,  then  atmospheric  quaht] 
ty  must  be  maintained  at  a  maximum. 

If  gain  to  health  were  proportional  to  air  supply,  a  use  of  1h.- 


302  VENTILATION   AND   HEATING 

largest  possible  supply  mighl  properly  be  urged,  as  also  an  un- 
limited spaciousness  of  rooms  which  would  permit  of  the  use  of 
fair  quantities  without  drafts. 

Somewhere  the  minimum  and  the  maximum  limits  Tor  air  must 
be  placed.  The  hospital  is  not  a  fitting  subject  to  invite  a  discus- 
sion of  such  minimum.  Of  all  places,  the  hospital  is  the  place  for 
maximums  in  all  that  can  increase  air.  Everywhere,  but  most  of 
all  in  the  hospital,  the  rule  of  ventilation  should  be  "the  maximum 
admissible,  rather  than  the  minimum  tolerable.'' 

The  cost  of  warming  air  for  ventilating  purposes  where  coal 
can  be  had  at  $5  per  ton,  and  where  the  outside  climate  during  the 
closed  season  averages  •*'>•">  degrees  F.  below  the  indoor  tempera- 
ture, and  where  fuel  is  not  badly  wasted  in  (ires,  is  I'd  cents  for 
each  1,000,000  cubic  feet  of  air  used,  equivalent  to  a  per  capita 
supply  of  4,00i>  cubic  feet  an  hour  for  ten  days  of  24  hours  each, 
or,  roughly,  two  cents  a  day  for  1,000,000  cubic  feet  of  pure  air! 

What  supply,  then,  shall  be  given  to  those  sick  with  infectious 
diseases,  to  restore  vitality,  to  dilute  and  remove  the  moribific 
contents  of  air,  to  protect  those  uninoculated  with  the  disease.' 
A  maximum  of  8,000  cubic  feet  per  hour  for  each  bed  is  surely  a 
rational  demand.  And  what  for  the  surgical  ward.'  Surely  a  per 
capita  supply  of  6,000  cubic  feet  an  hour  is  a  moderate  maximum. 
Koi-  the  medical  ward,  and  for  average  cases,  that  limit  may  be 
fixed  at  4,000  cubic  feet  an  hour  for  each  bed,  as  a  maximum. 

Massing  from  general  principles  to  some  of  the  more  specific 
methods  to  be  followed  in  the  ventilation  of  hospitals,  the  first 
suggestion  relates  to  the  importance  of  so  ventilating  some  parts 
of  the  hospital  as  to  protect  others  than  the  patients  occupying 
them,  or.  in  other  words,  the  use  of  such  a  method  of  ventilation 
in  particular  cases  as  shall  prevent  the  escape  of  air  from  the  af- 
fected rooms  to  other  rooms,  or  to  corridors  connecting  with  such 
rooms.  Such  ventilation,  to  be  effective,  must  isolate  that  room, 
atmospherically,  from  its  surroundings.  To  accomplish  such  a 
result  its  provided  discharge  ventilation  must  be  in  excess  of  its 
provided  supply  ventilation.  Booms  requiring  su<'h  so-called 
•'vacuum  ventilation"  are  contagious  wards,  private  or  general, 
sanitary,  operating,  mortuary,  etherizing  and  bath  rooms,  kitchen 
quarters,  lockers  and  lavatory  rooms.  The  major  force  operating 
to  ventilate  these  rooms  should  be  on  the  side  of  discharge  rather 
than  on  that  of  supply.  'The  air  of  corridors  and  adjacent  rooms 
would  then  tend  to  move  toward  and  into  the  vacuum  ventilated 
rooms,   rather  than   from   such   rooms  into  surrounding  quarters. 

The  means  required  to  accomplish  these  results  are  a  proper 
size  of  exhaust  or  discharge  flues,  and  sufficient  strength  and  sure 


VENTILATION   AND   HEATING 

ness  of  draft  in  them.  Such  means  are  easily  obtainable  by  a 
proper  area  of  flue,  height  of  flue  and  heal  in  Que  or  by  a  suit- 
able fan  power  connected  with  the  exhansl  part  ot  the  ventilating 

s\  stern.  .  „  , ,      ,         •  ,    i 

'  The  second  suggestion  is  thai  other  sections  of  the  hospital 
should  have  a  greater  strength  of  ventilating  work  on  the  supply 
rather  than  on  the  discharge  side.  Such  ventilation  should  be 
furnished  to  all  wards,  private  or  general,  for  other  cases  than 
infectious,  and  for  all  living,  administrative  and  work  quarters, 
other  than  those  named  as  more  properly  ventilated  by  a  pie- 
dominance  in  vacuum  action. 

Bv  maintaining  a  condition  of  lower  atmospheric  pressure  m 
those  parts  of  the  hospital  which  should  he  atmospherically  isolat- 
ed and  by  maintaining  at  the  same  time  a  higher  pressure  in  those 
parts  which  should  be  protected,  the  trend  of  air  movement  is  made 

to  set  from  the  quarters  in  which  the  air  should  be  maintai 

at  its  purest,  toward  and  into  those  in  which,  from  one  cause  and 
another,  the  contained  air  must  of  necessity,  and  may  without 
harm  he  more  or  less  contaminated  by  impurities  which  vary 
from  the  dangerous  to  the  offensive  and  to  the  relatively  inno- 

"entThe  third  suggestion  is  that  what  should  be  done  in  the  man- 
ner described  for  the  hospital  as  a  whole  should  also  be  done  for 
special  quarters.    There  is,  for  instance,  no  adequate  justification 
for  allowing  the  offensive  odors  attending  excrement*]  discharges 
escape  from  water  closet  seats,  and  to  diffuse  through  rooms 
for  dilution  in  air  previous  to  its  brea thing    nor  tor  th         , 
steam    smoke  and  fumes  from  a  range  to  Ml  the  entire  kitchen 
before  any  attempt  is  made  to  remove  them.     Here    again,  the 
drift  of  air  movement  should  be  toward  the  vitiated  locality,  so 
ouglv.  surely  and  continuously  that  the  offenses  shall  be  con- 
fined to  the  place  of  their  origin,  and  removed  without  so  much 
as  a  chance  of  mixing  with  air  the  purity  of  winch  should  be  mam- 
tained  for  breathing.  ,. 

The  general  law  governing  these  matters  and  applicable  to  ..II 
ventilating  work,  and  designed  ...  insure  effectiveness  and  economy 
in  that  work,  is  that  of  limitation  and  removal  by  satura ion,  as 

against  diffusion  and  removal  by  dilution.       en  cubi    

a  minute  moving  toward,  in,...  through  and  ou<    Iron.       wate' 
closet  seat  will  more  effectively  protect  the  room  against  excre- 
mental  offenses  than  ten  or  twent,    times  that   quantity  ot     ir 
passed  llmmgl.  the  room  itself    just  as  the  throat  of  a  fireplace 

v  ,   ■     ,e  lum.lred  feet  of  air  and  s ke  a  minute  from  the  fire 

Crn  fg  on  the  hearth  will  keep  ,1.- n>  in-  from  tear-making 


304  \  KXTILAl  I(>:\    AND   HEATING 

smoke  as  1,000  cubic  feet  per  minute  would  not,  and  could  not,  if 
the  same  fire  burned  on  an  open  hearth,  as  in  the  olden  tune,  in  the 
center  of  the  room. 

METHOD  OF   VENTILATION. 

There  is  one  method  of  ventilation  among  the  many  which, 
when  admissible,  is  incomparably  the  best  in  simplicity,  efficiency 
and  economy.  The  method  is  the  wind,  and  the  means  the  windows. 
Tn  the  quantity  of  air  moved  and  in  the  effectiveness  of  ventilat- 
ing work,  human  ingenuity  and  enginery  cannot  approach  the 
results  obtained  by  perflation. 

Artificial  ventilation  can,  at  the  best,  be  only  a  substitute  for 
such  natural  ventilation.  Artificial  ventilation  is  necessarily  no 
more,  nor  no  hotter,  than  a  substitute  for  that  which  is  natural  and 
perfect.  Xo  forcing  of  air  through  provided  ways  and  ramifying 
lines  by  spanking  it  with  paddle-fan  blades,  or  putting  it  through 
the  screws  of  the  propeller-fan,  or  torturing  it  with  hot  irons  of 
steam  beaters  can  make  it  do  all  it  stands  waiting  to  do  if  given 
the  adequate  opportunity  for  its  own  work  in  its  own  way. 

The  insuperable  obstacle  to  the  universal  and  continuous  use 
of  the  natural  or  open-window  and  door  method  is  in  the  nature 
of  outdoor  climate  during  the  portion  of  the  year  when  artificial 
ventilation  must  be  resorted  to.  Only  in  the  equatorial  zone  and 
adjacent  territory  is  free  and  abundant  ventilation  by  Nature's 
methods  possible  during  the  entire  year.  Tn  the  temperate  and 
colder  /ones  artificial  warmth  must  be  maintained  in  buildings 
for  occupancy  during  fully  one-half,  or  more,  of  the  year.  Out- 
ride cold  must  be  excluded,  and  as  air  in  its  natural  condition 
cannot  be  admitted  without  also  admitting  cold,  a  limitation  must 
l»e  placed  upon  the  air  supply,  and  therefore  upon  ventilation. 
That  fact,  however,  does  not  wholly  preclude  a  use  of  the  natural 
method,  even  in  the  cold  noil  hern  winter  season.  What  cannot 
be  continuously  used  with  safety  may  be  temporarily  used  with 
profit.  Wards,  living  rooms,  dining  rooms,  almost  all  quarters  of 
lh<-    hospital    may    be   advantageously   flushed   with     an     in-flow, 

through-flow  and  out-flow  of  the  purest.   st   invigorating  and 

least  "doctored  and  manipulated"  air  obtainable.  For  the  pur- 
pose of  making  such  a  method  of  ventilation  usable  and  useful 
to  the  maximum,  architects  could  provide  for  it  by  furnishing  tran- 
som  window-,  which,  when  opened,  will  throw  the  entering  air 
upward  and  reduce  floor  drafts  to  a  minimum.  Such  transoms 
should  be  furnished  with  checks  for  preventing  a  lateral  inflow  of 
air  and  for  insuring  an  upward  flow  only.  The  air  currents  will 
then  expend  their  draft  force  near  the  ceiling,  the  entering  cool 


VENTILATION   AND    BEATING 


:;m: 


air  will  mingle  with  the  warm  air  of  the  upper  room  before  de- 
scending to  the  floor;  drafts  will  be  reduced,  and  inflowing  air 
will  be  tempered  before  the  breather  is  reached.  The  benefits  of 
such  a  method  of  ventilation  are  important  and  large,  provided 
the  inflow  of  air  is  free  and  that  harmful  drafts  and  chilling  effecl - 
are  eliminated. 

Continuous  ventilation  of  the  same  type,  bill  much  more  lim- 
ited in  degree,  may  he  had  by  filling  the  opened  sash  spaces  of 
windows  with  a  cloth  of  open  mesh,  such  as  the  finer  grades  of 
cheesecloth.  The  cloth  may  be  stretched  on  frames  similar  to, 
or  identical  with,  those  of  fly-screen  frames.  For  mild  cold 
weather  a  single  thickness  of  such  cloth  may  answer,  and  for 
colder  weather  one  thickness  of  the  cloth  on  each  side  of  the 
frames.  This  method  requires  a  surface  cloth  corresponding  to 
the  rate  of  air-flow,  or  of  its  diffusion  through  the  cloth  between 
the  inside  and  outside  air.     A  square  yard  to  each  breather  is  a 


fig.  176. 

Panel    to    be    inserted    under    raised    sash. 

fair  amount  of  surface,  if  the  outside  air  is  quiet,  and  if  the  con 
ditious  within  are  not  such  as  to  make  the  inward  movement  of 
air  too  rapid  for  its  proper  warming.  The  action  in  the  case 
of  the  double  stretch  of  cloth  is  partially  one  of  warming,  since 
the  in-moving  air,  which  is  cold,  meets  and  diffuses  with  the  out 
going  air,  which  is  warm,  the  latter  imparting  a  considerable  pari 
of  its  heat  to  the  cold  and  inward  moving  air. 

The  method  has  been  found  applicable  to  and  advantageous 
in  the  sick  room  of  private  residences,  and  it  may  be  easily  and 
profitably  applied  to  the  wards  and  other  rooms  of  hospitals  which 
are  without  incorporated  systems  of  ventilation. 

A  more  modern  method,  however,  than  the  one  suggested 
above  is  the  insertion  into  the  windows,  either  in  panel  form  as 
shown  on  Figs.  176,  177,  or  making  provision  in  the  lower  sash  for 
one  of  the  several  forms  of  so-called  natural  ventilators,  which 
are  here  illustrated.     Figs.  L78,  179,  L80,  181  show  two  forms  of 


306 


V  E  XII  LATIO  X    \  X  ! )    II  I  AT  I  X  U 


these  ventilators,  the  first  having  an  automatic  device  for  the  con- 
trol of  air  by  means  of  a  swinging  shutter;  the  second  acting  in 
the  same  manner  as  the  first  without  the  shutter,  and  in  conse- 
quence  avoiding  the  rattle  which  might  occur  in  the  former.  Figs. 
177.  L82  show  a  form  of  ventilator  which  can  be  put  in  the  lower 
sash  of  the  window,  and  also  in  the  upper  sash  if  necessary,  and 
is  particularly  adaptable  to  natural  ventilation  in  hospitals.    Fig. 


FIG.  177. 
Panel  form  of  8  in.  oblong   ventilator. 

183  shows  another  form  of  ventilator  in  which  the  air  supply  can 
be  regulated  to  some  extent,  but  in  this  form  it  is  necessary  to 
open  the  window  and  leave  it  so  sufficiently  to  admit  of  the  putting 
in  of  the  ventilator.  Fig.  184  shows  one  of  these  ventilators  put 
into  the  masonry  work  of  the  building',  preferably  in  panels  under 
the  window;  they  are  hoth  efficient  and  sightly  in  this  form.      The 


FIG.  178. 
[nside  of  exterior  hood,   showing  swinging  shutter. 

advantage  of  so  placing  these  ventilators  is  obvious,  inasmuch  as 
the  air  entering  conld  be  brought  directly  in  contact  with  the 
heating  surface  of  the  radiator,  and  the  chill  taken  off  in  this 
manner. 

A.s  is  stated  below,  the  inlets  for  the  air  should  be  between 
beds,  if  possible.  In  all  forms  of  natural  ventilation  it  will,  of 
course,  be  necessary  to  have  some  outlet  for  the  air  in  the  room  in 


VENTILATION    AND    ill.  ATI  N A , 


307 


order  to  create  the  circulation  necessary  for  ventilation.  In  gen- 
eral hospitals  doors  should  be  provided  with  transoms,  as  stated 
elsewhere,  and  the  corridor  could  thus  be  made  a  large  and  vol- 
uminous vent-duct,  which  would  be  more  than  sufficient  for  all 
ordinary  needs,  so  far  as  the  quantity  of  air  to  be  conducted  is 


fig.  179. 

Inside  of  exterior  hood  square  ventilator. 

concerned.  If  this  is  done,  however,  it  wrill  be  necessary  to  place 
at  the  opening  of  each  corridor  some  adequate  means  for  carrying 
off  the  air,  which  would  come  into  the  corridors  through  the  tran- 
soms from  the  rooms.  This  can  be  accomplished  in  several  ways 
— namely,  the  creating  of  a  slight  draft  by  means  of  a  radiator 
placed  below  the  windows,  and  the  use  of  some  form  of  screen 


fig.  180. 

Outside  "i  exterior  hood  square  ventilatoi 

work,  or  a  number  of  ventilators,  at  the  top  of  the  window.  This 
will  also  serve  the  double  purpose  of  keeping  the  air  in  such  cor- 
ridors somewhat  purer,  and  at  the  same  time  keeping  them  at  a 
temperature  such  as  will  be  required. 

The  same  objeel  can  he  accomplished  by  the  building  of  duets 
through  the  wall  above  tli<'  window.  This  would  create  ;i  through 
draft  in  the  corridor  and   would  also  act   in   the  same  manner  as 


308 


YHNTII..\T1<>\    \XI»    HEATING 


described  for  the  ventilators,  the  entire  action  being  enhanced  by 
the  warm  air  from  the  radiators  heneath  the  windows,  rising  and 


fig.  181. 

[nside   of   interior   diffusion   box    for   square   ventilator. 

flowing  through  the  openings  provided,  and  in  this  manner  creat- 
ing a  continuous  air  flow. 

The  capacity  of  these  ventilators,  which  are  to  be  put  into 


FIG.    182. 
Oblong   ventilator    for   sash   installation.     Interior   hood. 

windows  or  walls,  as  the  case  may  be,  have  been  figured  by  ex- 
perts, but  these  figures  are  not  as  reliable  as  they  should  be,, 
owing  to  the  fact  that  all  such  ventilators  are  subject  to  the  ve- 


VENTILATION    MSB    HEATING  309 

locity  of  the  air  currents.  A  fair  average  lias  been  taken  of  the 
air  moving  at  20  miles  per  hour.  Nevertheless,  it  is  not  safe  to 
figure  on  a  capacity  with  such  a  velocity,  and  a  minimum  is  there- 
fore taken  for  the  basis  of  their  calculations— ten  miles  per  hour 
being  such  a  minimum.  This  is  equal  to  880  feet  per  minute,  and 
would  give  the  capacity  of  the  air  intake  on  the  following  sizes  of 
ventilators : 

3-inch  ventilator 65  cubic  feet  per  nun.it.' 

5-inch  ventilator 108  cubic  feet  per  minute 

7-inch  ventilator 150  cubic  feet  per  minute 

9-inch  ventilator 193  cubic  feet  per  minute 


nlffllii  Li 

fig.  is:;. 
The  capacity  of  the  oblong  ventilator  can  be  figured  from  this, 
and  owing  to  the  fact  that  it  is  more  easily  adapted  to  constructive 

detail,  is  the  one  recommended. 

A  very  simple  method  devised  Tor  heating  and  ventilating  is 
the  direct,  indirect  method,  one  which  has  been  used  to  some  extent 
in  hospitals.  The  heating  is  all  direct,  the  air  coming  in  through 
louvers,  passing  through  a  register  which  can  be  opened  or  closed 
at  will,  back  of  which  is  an  extremely  line  mesh  screen  which  is 
removable,  so  that  it  can  he  readily  cleaned  (Fig.  1.85).     All  the 


310 


\  KX'TIi,  \  I  I  ( )  X    A.ND    I1KA  i  l.\(, 


air  goes  into  a  duct,  two  screens  made  of  cheesecloth  and  remov: 
able  being  interposed.  These  can  he  made  damp  and  changed 
as  required.  At  the  bottom  of  the  duct  are  two  small  doors, 
through  which  can  be  placed  a  pan  of  water.  This  will  serve  the 
double  purpose  of  taking  up  the  particles  which  may  got  in  and 
of  giving  humidity  to  the  air.  The  air  falls  directly  over  the 
radiator  through  the  duct,  and  this  duct,  being  back  of  the  radiator, 
the  chill  is  taken  off  the  aii'  primarily.     It  then  rises  and  traverses 


fts 


^o 


V'"W* :'&■?:.<  ?'..     '.  •■-■A  ^kk$ 


^.'iiiiiSiP'' 

FIG.  184. 

the  entire  room  to  the  duel  at  the  floor,  whirl]  lend-  to  a  large  air 
chamber  in  the  attic  space  between  ceiling  and  roof,  giving  room 
for  a  greal  volume  and  thus  a  regular  circulation.  This  attic 
space  is  ventilated  by  a  shaft  thirty  feet  above  the  roof  and  may 
be  made  to  work  either  naturally  or  mechanically,  the  first  by 
means  of  a  cowel  facing  the  aperture  from  the  wind  and  so  creat- 
ing a  vacuum  directly  in  front,  and  a  plenum  state  directly  behind 


VENTILATION    AND   HEATING 


311 


the  shaft.  A  simple  mechanical  process  is  the  placing  of  a  radiator 
of  large  capacity  at  the  base  of  the  shaft  or  duct  and  so  creating 
a  current  of  air  by  convection.  An  ordinary  gas  jet  at  the  bottom 
of  each  shaft  will  in  many  instances  suffice.  This  method  has 
many  strong  advocates.  With  this  system  all  screens  should  he  of 
uniform  size,  so  that  at  regular  intervals  they  can  be  changed  in 
the  entire  building.  With  the  help  of  an  orderly  or  janitor  a 
nurse  can  do  this.    The  work  requires  intelligent  supervision,  but 


fig.  185. 

this  in  hospitals  is  easily  obtained,  as  the  superintended  of  nurses 
could  have  the  entire  matter  in  charge.  Corridors  as  mentioned 
can  be  used  instead  of  the  above  method. 

Though  little  heed  may  be  given  to  Nature's  pari  in  the  proc- 
ess, the  correct  designer  of  a  method  for  air  diffusion  must  yet 
appreciate  the  necessity  of  evenly  distributing  and  diffusing  the 
air  employed.  If  he  is  versed  in  methods,  or  resourceful  in  devis- 
ing them,  he  will  be  able  to  suggest  a   variety  of  courses   to  be 


312  VENTILATION  AND  HEATING 

followed,  according  to  the  circumstances  which  may  require  or 
favor  them. 

Distribution  may  be  effected  by  either  of  the  following  gen- 
eral methods:  First,  through  a  multitude  of  scattered  and  well- 
placed  points  for  inflow  and  outflow,  or  by  a  single  point  for  out- 
ilow  and  many  and  distributed  points  for  inflow. 

The  usual  and  the  usually  adequate  method  is  to  concentrate 
either  the  inflow  or  the  outflow  into  one,  two  or  more  points,  and 
i.'  so  distribute  the  apertures  for  the  opposite  service  as  to  effect 
the  desired  distribution. 

For  certain  reasons  to  be  now  mentioned  preference  is  to  bfi 
u  i  n  *  - 1 1  to  a  diffusion  of  supply  and  to  a  concentration  of  discharge. 
Kirst,  if  wards  are  warmed  by  the  air  which  ventilates  them,  heat 
is  better  distributed  by  issuing  into  a  large  room,  as  a  ward,  at 
many  points,  rather  than  at  a  single  point.  In  the  second  place, 
draft  effects  are  much  less  for  equal  volume  movements  and  equal 
apertures  when  they  converge  for  discharge  than  when  the  con- 
centrated current  of  inflow  continues  its  shaft-like  course  athwart 
the  room.  An  indraft  of  air  will  move  in  more  or  less  compact 
current  from  one  side  of  a  room  to  another,  or  through  the  entire 
length  of  the  ward,  whereas  outflowing  air  moves  towards  its 
exits  through  that  pa  ft  of  a  sphere  which  is  made  possible  by  the 
conformation  of  walls  and  floors,  and  the  flow  becomes  perceptible 
as  a  draft  only  with  more  or  less  close  approach  to  the  aperture 
of  discharge.  Therefore,  concentration  in  outflow  is  less  open  to 
objection  than  aggregation  of  inflow. 

The  most  convenient,  as  well  as  the  most  effective,  place  for 
the  inflow  of  air  into  wards  is  beneath  windows.  Fresh  air  is 
then  issued  into  the  wards  between  beds  and  close  to  patients,  and 
the  current  of  cold  air  flowing  down  over  the  windows  is  met  and 
neutralized  by  a  flow  of  warm  air  rising  upwards  beneath  the 
window-.  Ideally,  such  an  inlet  should  be  beneath  each  window. 
IF.  however,  they  are  placed  at  alternate  windows,  each  bed  has 
then  a  supply  furnished  on  one  side.  The  unused  wall  Space  be- 
tween cots  at  the  remaining  windows  affords  table  accommoda- 
tion to  each  bed.  The  position  of  the  register  in  such  a  location 
should  be  high  enough  above  the  floor  to  prevent  the  register  box 
from  becoming  a  dust  receptacle,  and  low  enough  below  the  win- 
dow sill  to  issue  the  air  sufficiently  near  the  floor  to  prevent  cold- 
ness at  the  tlooi-  level. 

With  such  an  arrangement  for  warm  air  inflow,  the  location 
of  discharge  may  be  I  trough  a  single  large  fireplace  ami  line  at  one 
"iid  of  the  ward,  provided  the  ward  is  intended  to  accommodate 
not    more  than   ten  or  twelve  beds.      Roughly,  then,  in  accordance 


VENTILATION   AND   HEATING 


with  such  a  plan,  each  twelve  beds  should  be  furnished  with  nol 
less  than  six  inlets,  and  with  not  less  than  one  ample  and  well- 
located  vent. 

Other  parts  of  hospitals  than  wards  require  adequate,  and 
in  some  cases  special,  ventilation.  The  operating  room  calls  for 
exceptional  treatment,  both  in  the  matter  of  ventilation  and  warm- 
ing. The  depressed  condition  of  the  vitality  of  the  patient  makes 
free  ventilation  imperative.  The  heat  must  be  uniform  and  thor- 
oughly under  control  in  the  coldest  weather,  day  and  night,  so  as 
to  be  available  in  case  of  emergency  operations. 

At  times  the  temperature  of  operating  rooms  becomes  op- 
pressive from  overheating  and  from  anesthetic  fumes.  Quickness 
of  air  change  is  then  called  for.  The  change  desired  can  best  be 
effected  by  giving  strong  exit  to  the  air  of  the  room  from  its  ceil- 
ing, where  air  is  hottest  and  vapors  are  densest.  The  air  is  com- 
monly and  properly  discharged  from  such  rooms  at  ordinary  times 
near,'  or  at,  the  floor.  If  the  area  of  the  floor-discharge  airway  is 
of  proper  size,  the  flue  having  connection  at  the  ceiling  may  be 
within  easy  reach  of  the  surgeon  or  his  attendants.  The  current 
which  controls  the  fan  may  also  operate  a  damper  for  closing  the 
opening  when  the  fan  is  not  in  operation  and  for  directing  the  out- 
flow to  the  vent  at  the  floor  of  the  room.  It  has  been  found  by 
experience  that  by  the  use  of  such  a  single  device  the  quality  of 
the  air  of  an  operating  room  may  be  given  the  quick  change  de- 
sired for  the  reduction  either  of  temperature  or  other  oppressive- 
ness or  offensiveness.  If  the  room  is  of  the  amphitheater  type, 
accommodating  a  large  number  of  clinic  observers,  a  fan  of  suit- 
able size  and  power  to  meet  the  special  conditions  is  required. 

A  better  way  to  accomplish  this  change  of  air  is  to  make  the 
ventilator  automatic  so  that  the  air-How  is  slighter  in  degree  than 
when  the  fan  is  in  operation. 

In  climates  of  central  and  northern  American  cities  the  car 
rying  off  of  the  oppressive  air  can  be  accomplished  by  ventilators 
in  the  skylights  over  the  room,  which  can  he  opened  or  closed 
sufficiently  to  equalize  the  air.  The  great  difficulty  has  ordinarily 
been  in  the  opposite  direction  where  artificial  ventilation  has  been 
supplied— i.  e.,  cold  air  falling  from  the  large  glass  area.  This 
may  be  overcome  by  building  all   skylights  double,  as  shown   in 

Figs.  64  and  88. 

For  the   ventilation   of   sanitaries,   bathrooms,   lockers  and   ol 
other  quarters,  a    slight    redaction   of  air  pressure  within  such 
rooms  should  be  maintained   in   order  to  insure  a   flow  ol    air  to 
ward  and  into  the.  from  adjacent  quarters.     It  the,  becomes  nee 
essarv  to   produce  in   the  vent-flues   tor  such   room-  a    stronger 


314  VEXTILATlOX    AXU    HEATING 

aspirating  action  than  in  the  ordinary  ventilating-flues  of  the 
building.  There  must  be  an  excess  of  "pull"  to  move  a  larger 
air  volume  than  is  moved  by  other  flues.  The  pressure  per  square 
inch  should  be  greater  than  is  the  pull  in  vent-flues  discharging 
air  from  other  and  ordinary  rooms,  but  the  area  of  the  flues  may 
be  small  in  proportion  as  the  ''pull"  is  strong.  To  effect  such 
excess  of  "pulling"  in  the  Hues  in  which  it  is  desired,  and  when 
dependence  is  placed  upon  gravity  action  for  the'  production  of 
ventilation,  it  becomes  necessary  to  heat  such  flues  by  some  ap- 
propriate means,  such  as  -team  coils,  hot  water  coils,  gas  or  lamp 
flame.  The  temperature  of  such  flues  should  be  raised  above  the 
temperature  of  the  flues  ventilating  ordinary  rooms  by  an  amount 
equal  to  ten  or  fifteen  or  sometimes  twenty-five  degrees.  Boughly 
speaking,  when  such  flues  are  heated  by  steam  surface  the  mini- 
mum amount  of  that  surface  which  can  be  safely  used  is  five  square 
feet  to  each  one  square  foot  of  cross  section  of  flue. 

Very  much,  perhaps  not  too  much,  has  been  written  and 
spoken  in  regard  to  the  importance  of  keeping  airways,  both  sup- 
ply and  discharge,  scrupulously  free  from  dust  and  dirt.  Clean- 
liness is  the  first  essential;  to  it  ventilation  is  secondary.  Dusti- 
ness and  dirtiness  are  less  of  a  menace,  however,  in  some  places 
than  in  others.  If  the  dust  is  in  a  flue  through  which  air  is  con- 
tinuously passing  outward  from  a  room,  the  room  is  in  no  way 
endangered  by  the  presence  of  such  dust  and  dirt,  If,  on  the  other 
hand,  the  menace  lurks  in  the  airway  from  which  the  room  is  sup- 
id  ied,  the  danger  is  the  greater. 

The  principal  danger  arising  from  dusty  vent  flues  is  in  possi- 
ble draft  reversals,  which  may  carry  with  them  the  objectionable 
dust  into  rooms.  If,  for  no  other  reason  than  for  the  sake  of  clean- 
liness, all  lodging  and  hiding  places  for  dust  are  to  be  avoided. 
A.s  far  as  is  practicable,  all  airways  should  be  accessible  for  the 
purpose  of  inspection  and  cleaning.  For  this  reason,  the  mouths, 
throats  ami  duct-ways  of  flues,  both  for  supply  and  for  discharge, 
should  be  as  open  ami  as  accessible  as  are  fireplaces  and  their 
flues. 

The  substitute  for  Nature's  method  ami  work  is  ventilating 
.mechanisms,  as  the  fan.  or  a  propulsion  of  air  through  ducts  by 
heating  the  former.  The  two  methods  are  designated  Mechanical 
and  Gravity  ventilating,  respectively.  The  larger  part  of  ventilat- 
ing work  the  world  over  is  to-day,  and  doubtless  will  be,  done 
without  mechanism. 

Where  the  airways  for  ventilating  work  can  be  large  enough, 
and  high  enough,  and  where  heat  need  not  be  used  for  the  sole 
purposes  of  producing  ventilation  (low,  there  ventilation  by  grav- 


VENTILATION   AND   HEATING 


315 


itv  action  is  always  admissible,  and  often,  if  not  -cue rally,  prefer- 
able. When  the  ventilating  work  to  be  done  is  small,  and  even 
when  the  volume  of  air  used  is  large,  but  its  use  is  intermittent 
and  at  long  intervals,  then  gravity  or  natural,  rather  than  me- 
chanical, ventilation  is  found  advisable.  Small  and  intermittent 
ventilating  work  does  not  warrant  the  expense  of  an  adequate  and 
largely  idle  equipment  and  the  salary  paid  to  a  competent  en- 


gineer. 


This  phase  of  the  ventilating  problem  resolves  itself  into  one 
of  operating  profit  and  loss,  into  which  enter  too  large  a  number 
of  factors  for  discussion,  or  even  mention,  in  our  present  study. 

In  general,  however,  this  rule  may  be  followed:.  When  ven- 
tilation is  to  be  continuous,  as  in  a  hospital;  wherever  the  air 
volumes  are,  or  should  be,  large;  where  airways  are  long,  or  small, 
and  the  velocity  of  air-flow  must  be  high;  where  power  is  avail- 
able in  steam  used  for  other  purposes,  or  in  electric  service,  or  in 
an  inexpensive  water  head  and  flow,  or  even  when  gas  or  like  en- 
gines can  be  advantageously  used;  when  required  attendance  may 
be  given  by  those  already  employed  for  other  service— then  the 
conditions  are  favorable  to,  and  frequently  require,  the  use  of 
mechanical  ventilation. 

An  argument  made  in  some  quarters  against  mechanical  ven- 
tilation for  hospitals  is  based  on  the  necessity  of  quietness  about 
the  sick,  and  on  the  assumption  that  the  use  of  mechanism  neces- 
sarily involves  the  noisy  whirl  of  wheels,  or  the  rumbling  or  clat- 
tery  of  machinery,  or  the  whistling  or  singing  of  the  air  as  it 
frolics  into  or  frisks  out  from  rooms  under  the  propulsion  of  the 
fan.    All  such  noisy  nuisances  are  quite  as  avoidable  as  they  are 

possible. 

A  frequently  used  substitute  for  the  fan  is  heat  in  vent  flues 
To  warm  air  for  admission  to  buildings  is  quite  costly  enough.    To 
again  heat  it  as  it  takes  its  flight   from  buildings  is  to  increase 
expense  in  a  manner  to  be  justified  only  when  other  equally  effec- 
tive methods  would  be  equally  or  increasingly  costly. 

Because  the  flue-heating  method  is  simple  and  easily  applied, 
and  because  its  costliness  is  current,  slowly  cumulative,  and  not 
conspicuously  evident,  it  is  often  employed  to  the  user's  loss.  To 
move  a  cubic  foot  of  air  into  a  building  through  a  heater  and  Pan, 
ami  through  flues  to  rooms  and  through  rooms  into  and  through 
vent-flues,  and  to  discharge  if  outboard,  all  requires  a  power  rarely 
reaching  and  never  exceeding  thai  required  to  raise  ten  pounds 
in  weight  through  one  foot  against  the  pull  of  gravity.  In  a  well- 
designed,  accommodated  ami   installed  system   of  ventilation  the 


316  \  KXTILAT10N  AND  HEATING 

work  expended  on  each  cubic  foot  of  air  moved  through  it  should 
not  exceed  from  live  to  six  pounds. 

If,  on  the  other  hand,  that  cubic  foot  of  air  is  made  to  move 
through  the  ventilating  system  of  the  building  by  giving-  to  it  a 
rise  of  temperature  of  ten  degrees,  for  the  purpose  of  producing 
an  acceleration  of  flow,  the  power-equivalent  of  that  beat  is  10 
pounds  raised  through  more  than  14  feet  against  the  pull  of 
gravity,  instead  of  10  pounds  raised  through  one  foot.  If  only 
one-twelfth  of  the  beat  produced  by  fuel  combustion  is  convertible 
into  power,  and  if  the  exhaust  steam  of  the  engine  furnishing  that 
power  is  wasted,  the  cosl  of  moving  the  air  by  raising  its  tem- 
perature ten  degrees  and  the  cost  of  moving  that  air  by  exception- 
ally hard  fan-work  are  then  about  equal.  If,  however,  the  exhaust 
steam  from  the  engine  driving  the  fan  is  used  for  heating  pur- 
poses, the  largest  cost  which  we  may  consider  allowable  by  the  fan 
method  is  about  one-third  of  that  by  the  heated-fine  method,  when 
the  rise  in  flue-air  temperature  is  but  ten  degrees.  The  higher 
the  rise  of  that  temperature  the  greater  the  loss. 

Kan-ventilation  is,  therefore,  to  be  generally  recommended  for 
large  hospitals  of  complicated  plan  and  construction,  where  air- 
ways must  be  small,  tortuous  and  long,  and  where  gravity  cannot 
be  given  generous  provision  for  its  own  moderateness  and  vari- 
ableness of  work. 

The  heating  of  hospitals  should  not  depend  upon  the  ventilat- 
ing air  as  a  carrier.  The  systems  should  be  entirely  independent, 
each  a  unit  in  itself,  for  the  following  reasons:  At  best  a  ventilat- 
ing plant  is  so  uncertain  in  its  operation  until  it  has  been  thor- 
oughly tested  that  to  make  the  ventilating  air  the  vehicle  also  for 
beating  is  to  put  the  latter  in  doubt.  What  will  work  properly  in 
one  building  will  not  necessarih  do  so  in  others  Precedent  is 
absolutely  unreliable.  We  are  dealing  primarily  with  a  theoretical 
problem,  and  while  theory  may  be  correct  to  the  minutest  detail. 
the  practical  working  of  the  plant  is  dependent  on  so  many  things 
that  it  is  not  safe,  especially  in  colder  climates,  to  depend  upon 
them  until  they  have  proven  eminently  satisfactory.  Direction  of 
wind,  general  conditions  as  to  building  material  am!  natural  leak- 
age of  air  through  these.  ;.ll  may  tend  to  npset  the  most  careful 
calculations.  Not  that  ventilating  is  not  an  exact  science  so  far  as 
it  goes.  bu1  rather  that  no  two  problems  present  the  same  latent 
conditions. 

The  element  of  chance  enters  largely  into  nil  calculations  of 
this  character.  Heating  follows  the  same  indecision  at  times,  for 
the  nnionnt  of  radiation  necessary  for  the  rooms  of  exactly  the 
same   size,  exposure,   window  area   and  general   location   will   be 


V  K  N  TI LATI0  X    AND    1 1  EAT  I  X  G  .">  1  7 

found  to  require  different  amounts  of  heating  surface.  In  the 
ease  of  radiation  this  is  easily  corrected,  inasmuch  as  additional 
loops  can  be  added.  In  ventilating  work,  however,  owing  to  the 
necessity  for  making  the  ducts  a  minimum,  rather  than  a  max- 
imum size,  so  that  they  occupy  as  little  of  valuable  space  as  is 
possible,  corrections  are  not  possible,  as  such  duets  are  built  in 
and  are  an  integral  part  of  the  building. 

Hospital  ventilation,  it  is  granted,  must  be  made  free;  that 
is.  the  air  quantity  must  be  abundant,  and  while  tins  abundance 
may  be  sufficient  for  conveying  heat  to  the  different  parts  of  the 
building,  this  indirect  method  of  heating  is  not  to  be  depended 
upon.  It  is  not  certain  enough  in  its  action,  nor  is  it  economical; 
iu  fact,  it  is  the  most  expensive  form  of  heating.  If,  however,  this 
method  is  used  the  coils  for  heating  the  air  to  warming  tem- 
perature should  not  be  iieated  by  steam.  The  air  passim''  over 
the  superheated  steam  coils  is  deteriorated  by  scorching  and  the 
odors  and  quality  peculiar'  to  such  air  are  neither  agreeable  nor 
hygienic. 

The  coils  for  this  purpose  should  be  heated  by  hot  water  and 
a  sufficient  quantity  of  this  should  be  supplied  so  that  it  can  be 
maintained  at  as  low  temperature  as  is  consistent  with  the  proper 
wanning  of  the  hospital.  The  temperature  should  not  exceed  L60 
degrees  F.  The  air  flow,  then,  being  rapid  over  these  coils  admits 
of  none  of  the  deleterious  effects  of  superheated  coils. 

This  has,  besides  the  reasons  stated,  the  element  of  economy 
mentioned.  First,  because  of  the  transfer  of  a  larger  proportion 
of  the  heat  combustion  to  radiators  than  when  steam  is  employed; 
and  second,  because  of  the  easier  and  more  complete  regulation  of 
the  building  temperature,  which  makes  less  liable  the  overheating 
of  rooms  in  mild  weather,  and  the  opening  of  windows  for  relief 
and  the  larger  waste  of  heat  attending  that  practice.  In  spring 
and  autumn  in  the  cold  climates,  and  in  the  winter  months  in 
milder  climates,  the  heat  necessary  may  all  be  supplied  for  warm 
ing  by  this  method,  as  it  would  be  sufficient  to  take  off  the  -light 
chill. 

AIR  FILTRATION   A XI)  WASHING. 

The  matter  of  washing  air  for  ventilating  work  when  fan 
systems  are  used  is  as  prolific  of  methods  as  is  ventilating  itself. 
There  are  several  methods  which  have  been  successfully  used., 
and  these  are  given  here.  All  air,  however,  for  ventilating  pur- 
poses when  fans  are  used  should  first  be  conveyed  to  a  settling 
chamber,  which  is  a  large  space  in  the  attic  or  basement  in  which 
the  air  is  permitted    to    come    somewhat    to   rest   and   to   permit 


318 


VENTILATION   AND    BLEATING 


the  larger  dust  particles  to  settle  out.  This  room  must  be 
kept  clean.  The  basement  room  is  not  recommended,  owing-  to 
the  danger  of  contamination  of  the  air  by  soil  air  and  oilier  gases. 
The  most  effective  method  for  making'  such  a  room  sanitary  and 
clean  is  to  line  it  with  tin  or  galvanized  iron  or  to  build  the  entire 
room  of  sheets  of  the  latter  with  tight  joints  and  stiffening  rods. 
If  it  is  not  possible  to  provide  chambers  large  enough  for  this 
settling  of  the  air,  a  very  good  method  is  shown  in  Pig.  186.  This 
consists  of  admitting  the  air  into  the  building  through  the  ordi- 
nary intake  and  dividing  this  into  smaller  ducts  whose  total  ca- 
pacity is  somewhat  in  excess  of  the  main  duet,  and  at  the  bottom 


fig.  186, 

of  these  securely  fastening  a  double  thickness  of  gunny-sack.  This 
serves  the  purpose  of  removing  the  larger  particles  of  dust  and 
leaving  only  the  minute  particles  for  the  washing  apparatus  to 
remove.  These  sacks  should  be  removed  at  least  once  in  every 
two  or  three  days,  and  others  put  in  their  place  while  the  first  are 
being  cleaned. 

The  best  methods  of  cleansing  air  are  'he  natural  ones.  Air 
which  has  been  carried  across  a  large  body  of  water  is  practically 
free  from  impurities,  because  these  have  fallen  into  the  water.  Air 
near  the  tops  of  high  mountains  is  pure  because  impurities  fall  to 
the  ground  before  they  are  carried  to  great  heights. 


VENTILATION  AND  HEATING 


319 


In  tall  buildings  there  are  more  micro-organisms  in  the  air 
entering  from  without  in  the  lower  than  in  the  upper  iioors. 

For  these  reasons  it  seems  wise  to  obtain  as  large  a  piece  of 
land  as  the  means  will  permit,  on  the  highest  available  piece  of 


t     ii    m  f    'Hi'  "t(    *i  <    ^  i     '>  (    >»  <   -*  <    a  i   -rr 


*   l      *\  i       M  <      AH       ''I  I      ■«  t       »)  f     -ti   1     II       '*   I      ^   f     -a  i     1 


/      3XZ5XZ3D      >t  f    *  i     ^  t     *  I     VM    a  f     vi  (  .  ?  (     Tt 


■*>  t    At     At     ■»  (     t)  I     'i  f      ■»!     <if     ^  (      *  <    '»  '     ^~t~* 


I       SB    I        II        1    I       «l       II        HI        II        'H       "M       'II      Ji-L^L 


,1  (      ■.)  (       HI       hi  I       *    f      'H  I       «M       ^   '      <'      11       '*  '    -3-J-.3 


I     .<t     n  i     .ii     m     -it  i     ii  i     -»t     'II    't  <     ">  i     "i  ■     ■" 


--H  r     n  ( 


II       )ll       Ml        ■«    I       •"'       i     I       II        1    1      •'»    t      'J 


FIG.  187. 
Plan  of  washing  apparatus. 

ground  and  then  to  construct  buildings  as  near  the  .•cuter  thereof 
as  possible.  The  higher  the  buildings,  the  better  will  be  the 
chances  of  obtaining  good  air  for  the  greatest  number  of  patients. 


320 


VENTILATION    \N1>    HE  VI  [NO 


Shrubs  and  trees  planted  between  the  building  and  the  sur- 
rounding streets  will  serve  to  niter  a  considerable  portion  of  the 
street  dust  out  of  the  air  before  it  reaches  the  building. 

In  forcing  air  into  a  building  for  the  purpose  of  ventilation  it 


Or- 


<T- 


is  possible  to  select  that  which  is  relatively  free  from  dust  and 
impurities  if  the  intake  has  its  opening  at  a  good  height  above 
the  roof  of  the  building,  but  in  such  a  position  that  the  prevailing 
winds  will  force  the  impurities  which  come  from  the  chimneys  and 
vent  pipes  away  from  the  intake 


VENTILATION    AND   HEATING 


321 


Many  devices  have  been  instituted  for  the  purpose  of  washing 
the  air  which  is  forced  into  a  building  by  fans.  Streams  of  water 
are  permitted  to  drip  over  moist  gauze  or  other  substances  in 
order  to  intercept  the  fine  particles  contained  in  the  air.  The 
advantage  of  this  treatment  of  the  air  lias,  however,  not  yet  been 


fig.  189. 

fully  and  satisfactorily  demonstrated,  although  many  authorities 
speak  well  of  it. 

A  method  which  has  been  used  frequently  by  the  government 
in  some  hospitals,  and  especially  in  its  larger  office  buildings,  is 
to  heat  the  air  above  freezing  poinl  and  then  pass  it  through  a 


32-2 


VENTILAI  [ON    A.Mi   HEATING 


wall  of  finely  sprayed  water.  One  excellent  method  of  doing  this 
is  shown  in  Figs.  187, 188.  A  small  pump  driven  by  the  same  power 
thai  drives  the  main  fan  returns  the  water  with  sufficient  head  to 
make  the  sprays.  Fig.  189  shows  the  spray-head.  The  small  com- 
partments are  about  eighteen  inches  square,  so  as  to  keep  the  water 
from  spreading,  and  thus  making  a  fine  spray  instead  of  a  very  fine 
continuous  film.  As  will  be  seen  in  the  illustration,  the  air  strikes 
the  continuous  screen  of  water,  which  takes  up  the  dust  particles, 
and  these  ran  to  the  gutters  and  thence  to  a  main  tank.    From  this 


FIG.  190. 

it  goes  through  filters  and  is  then  returned  by  the  pump.  The 
filter  must  be  kept  clean  and  free  from  dirt  at  all  times.  The  air 
passing  through  the  water  screen  contains  a  quantity  of  moisture 
in  excess  of  what  is  good  for  ventilating  purposes.  The  angled 
surfaces  of  copper  permits  the  air  to  strike  on  the  plates  in  such 
a  manner  as  to  virtually  " shake  out"  the  unnecessary  water  parti- 
cles. This  is  partly  due  to  the  deviousness  of  the  path  of  the  air 
and  to  the  natural  condensation  on  these  plates.  The  air  goes 
from  these  plates  into  a  drying  room  and  from  there  into  a  space 
where  a  fine  spray  gives  it  the  requisite  moisture,  the  drying  room 


VENTILATION   AND   HEATING 


323 


being  kept  at  a  temperature  so  that  the  air  goes  out  to  the  several 
ducts  at  a  bit  higher  temperature  than  that  of  the  rooms. 

The  system  has  been  found  very  satisfactory  and  simple.  It 
is  also  economical  in  operation,  owing  to  the  fact  that  the  water 
can  be  filtered  and  used  over  and  over  with  renewal  for  loss. 


fig.  191. 
In  general  all  ventilating  systems,  natural  or  mechanical,  must 
supply  a  sufficient  amount  of  pare  air  at  all  times,  which  has  not 
been  spoiled  by  overheating,  which  is  delivered  throughout  the 
hospital  without  draughts  and  at  an  expense  which  is  within  the 
means  of  the  hospital  for  maximum  results. 

BEATING. 

Heating  may  be  dene  by  <>ne  el'  two  methods     hot   water  or 
steam.    The  primary  principles  Tor  these  are  practically  the  same 


:;i'4 


VENTILATION   AND    HEATING 


Damely,  thai  there  should  be  sufficienl  radiation  for  each  and 
every  space  to  be  heated.  An  excess  of  radiating  surface  is  to 
be  desired  at  all  times  rather  than  'Must  enough,"  or  too  little. 
The  pipes  should  be  sufficiently  large  to  do  the  work  noiselessly 
and  positively;  the  boilers  of  whatever  type  should  have  suffi- 
cienl capacity  to  easily  take  care  of  the  radiation  with  an  excess 
added,  whose  minimum  should  be  at  least  50  per  cent,  greater  than 
the  radiation  supplied.  This  latter  requirement  has  the  great  ad- 
vantage of  positive  work  and  the  item  of  economy  in  its  favor. 
This  reserve  allow-  for  main  risers,  How  and  return  pipes,  which 
must  be  considered  as  radiation,  and  a  twenty-five  per  cent,  re- 
serve capacity,  which  allows  for  leakage  of  air  into  the  building 
through  natural  means  and  through  faulty  fitting  doors  and  win- 


FIG.  192. 

dows.  An  expenditure  of  in  per  cent,  added  to  the  first  cost  of  a 
boiler  of  just  sufficient  capacity  is  so  small  thai  i\  cannot  be  men- 
tioned as  an  expense.  Moreover,  an  apparatus  which  needs  no 
"crowding-"  to  maintain  a  given  temperature  will  make  a  saving 
within  one  year  on  coal  consumption  alone  which  will  more  than 
.pay  the  additional  cost. 

BorLEES.  -Boilers  are  of  two  types  cast  iron  and  those  made 
of  steel  in  plate  form.  There  are  several  types  of  each  of  these — 
namely,  the  round  boiler  where  the  sections  are  superposed,  and 
the  square  boiler  where  they  are  set  horizontally  in  the  cast  iron 
type,  as  shown  in  Figs.  190,  191.  These  boiler-  are  not  adapted  to 
pressure  work,  and  are  designed  solely  for  either  low  pressure 
steam   plants  or  hot   water  heating  plants.     Of  the  wrought  steel 


VENTILATION  AND    HEATING  325 

type  there  are  upright  tubular  boilers,  locomotive  lire  box  boiler-, 
and  the  horizontal  tubular  boiler  with  furnace  attached.  Of  the 
latter  there  are  again  several  types — namely,  the  Marine  boiler, 
and  the  internally  fired  boiler.  Furnaces  for  the  tubular  type  are 
of  so  many  varieties  that  it  would  be  impossible  except  in  a  sep- 
arate treatise  to  mention  them  all.  Fig.  192  shows  the  upright 
tubular  boiler;  Fig.  193  shows  the  locomotive  fire  box  boiler,  and 
Fig.  194  shows  the  tubular  boiler  with  furnace. 

The  existing  conditions,  the  amount  of  variation  necessary  for 
heating  the  building,  and  the  general  structural  features  of  the 
building  will  be  the  best  guide  for  the  type  of  boiler  to  be  used 
in  any  given  case.  In  the  fire  box  and  tubular  type  of  boilers  it 
will   be  necessary  to  brick  the  boilers  in  masonrv.     The  boilers 


fig.  193. 

should  be  set  on  good  concrete  foundation,  and  the  side  walls  from 
these  foundations  should  be  made  of  good.  hard-burned  brick  to 
the  thickness  of  twelve  inches,  so  built  as  to  form  a  return  line, 
so  that  the  products  of  combustion  will  pass  through  the  flues, 
thence  down  under  the  shell  of  the  boiler,  and  then  rising  to  ba 
carried  over  the  top  of  the  boiler  to  the  smoke  (Inc.  The  irppei 
shell  of  masonry  should  be  thoroughly  plastered  over  with  asbes- 
tos cement. 

In  the  horizontal  type  of  cast  iron  boilers,  and  also  in  sonic 
instances  in  the  round  type,  a  heavy  coating  of  asbestos  cement 
should  be  put  on  at   least    four  inches  thick,  and   the  whole  thoi 
o uglily  covered  with  canvas.    The  capacity  of  these  boiler-  is  men- 
tioned elsewhere  ami  should  be  carefully  considered. 

If  more  than  one  boiler  is  used,  and  Ibis  is  thoroughly  advo- 
cated in  all  instances,  cross-connection  should  be  made  by  means 


326 


VENTILATION   AND    HEATING 


of  angle  valves  so  that  both  boilers  can  be  operated  at  the  same 
time  or  either  independent  of  the  other.  These  angle  valves  are 
to  be  iron  bodied,  brass  mounted  and  equipped  with  an  iron  wheel 
In  li<>t  water  heating,  it  will  be  necessary  to  follow  the  same  course 
on  the  return. 

The  great  advantage  of  a  double  battery  is  the  fact  that  in 
mild  weather  only  one  boiler  need  be  used,  and  also  in  the  lad 
that  in  ease  of  accident  to  one  boiler  the  other  can  still  be  operated. 
without  the  necessity  of  closing  down  the  entire  plant. 

Smoke  Breeching. — The  breeching  from  the  boilers  or  the 
smoke  pipe  which  runs  to  the  chimney  flue  should  be  made  of  suffi- 
cient heaviness  to  insure  its  not  warping,  and  should  not  be  of 
less  gauge  than  No.  12  galvanized  iron,  and  the  area  of  this  should 
not  be  less  than  25  per  cent,  greater  than  the  combined  boiler  flues. 


FIG.  1!>4. 

This  also  applies  to  the  chimney  area,  which  must  be  carefully 
calculated.  It  will  be  accessary  to  put  into  the  breeching  a  clean- 
ont  door  and  the  necessary  dampers. 

('mi.  OPENING.— As  will  be  noted  under  plumbing,  coils  for 
the  heating  of  the  domestic  supply  of  water  in  the  building  are 
sometimes  put  into  the  boiler  to  act  as  auxiliary  to  the  small  heal  sr 
or  the  garbage  crematory,  which  is  put  in  for  the  special  purpose 
<»f  heating  the  water.  Such  auxiliary  coils  are  used  more  often  in 
small  institutions  rather  than  in  the  larger  ones.  The  opening 
for  these  coils  should  be  placed  well  above  the  grate-,  and  about 
14  inch  centers,  and  the  pipes  to  these  should  not  be  less  than  two 
inches  in  diameter.  In  aearly  ail  cases  this  can  be  dene  wry 
readily  without  interfering  with  the  fire  and  still  be  made  very 
effective.  A  valve  should  bo  placed  on  .he  pipe-  outside,  so 
that  if  it   is  necessary  to  close  off  this  part  of  the  water  heating 


VENTILATION  AND  HEATING  327 

system,  it  can  be  done  without  interfering  with  the  remainder  of 
the  system. 

Radiation. — Direct  radiation  should  be  selected  with  due  ref- 
erence to  plainness,  smoothness  and  accessibility  to  surface  for 
cleaning.  All  radiators  should  be  placed  next  to  exposed  walls 
and  as  near  windows  as  possible,  as  these  are  the  coldest  portions 
of  the  room.  In  general  the  rooms  to  be  warmed  must  each  be 
given  the  amount  of  radiation  for  the  proper  warming  of  the 
space.  The  calculation  for  this  depends  upon  the  size  of  the  room 
— namely,  cubic  contents,  amount  of  exposed  wall  area,  the  quan- 
tity of  glass  in  the  room,  the  height  of  ceiling  and  the  position  of 
ventilators. 

"In  the  matter  of  warming  as  well  as  of  ventilation,  the  oper- 
ating room  furnishes  opportunity,  if  not  necessity,  for  special 
treatment.  The  effect  on  the  patient  of  the  large  exposure  of 
chilled  window  glass  should  be  compensated  by  a  correspondingly 
large  heated  surface.  That  surface  may  be  in  pipe  form,  carried 
about  the  window  frame  and  over  mullions  and  other  parts  of  the 
framework,  in  a  manner  to  be  neither  conspicuous  nor  light  inter- 
cepting. When  windows  are  double  glazed,  and  with  ample  air 
space  between  the  plates,  that  space,  and  with  it  the  inner  glass, 
may  be  warmed  by  steam  or  hot  water  pipes  concealed  from  view 
within  the  space." 

Systems. — As  stated  above,  and  for  reasons  there  given,  econ- 
omy favors  the  use  of  water  at  both  ends  of  a  system — at  the 
fires  and  at  the  radiators.  The  first  cost  of  a  hot  water  plant, 
for  equal  heating  work  with  steam,  varies  from  30  to  50  per  cent, 
more  than  the  cost  of  a  steam  apparatus.  The  saving  in  fuel  by 
water  boiler  heating  has  been  found  by  careful  experiment  to 
vary  from  15  per  cent,  to  20  per  cent,  as  compared  with  that  of 
doing  the  same  work  by  steam.  The  necessity  of  bringing  the 
water  to  the  boiling  point  in  a  steam  plant  is  entirely  eliminated 
in  the  hot  water  system,  for,  as  will  be  explained,  the  highesl 
temperature  used  would  be  190  degrees.  In  Hie  mild  days  of  early 
spring  and  late  fall,  a  temperature  of  from  90  to  1  in  degrees  will 
keep  the  building  at  the  proper  temperature.  In  chilly  days,  if  a 
steam  plant  were  installed,  it  would  be  necessary  to  raise  the  water 
to  a  temperature  of  212  degrees  in  order  to  heat  the  room-  or  to 
install  a  vacuum  system. 

In  high  buildings — namely,  those  of  five  stories  and  over  - 
an  auxiliary  pump  would  be  necessary  to  facilitate  the  flow  of  the 
water  in  the  hot  water  system.  This  might  be  advanced  as  an  ob- 
jection, due  somewhat  to  the  increased  cosl  of  such  apparatus. 
This,  however,  would  be  offset  by  the  fact  that  in  such  buildings, 


328 


VENTILATION   AND    BEATING 


if  steam  were  used,  additional  fuel  to  maintain  a  pressure  neces- 
sary to  heal  the  upper  floors  would  be  required.    Another  added 


FIG.  195. 
Hoi   water  heating.     Overhead  gravitj    system 

advantage  of  the  hot  water  is  thai  heat  can  be  maintained  in  the 
hospital  over  night  without  additional  firing,  other  than  "bank- 


VEXTILATIOX   A  X I '    II  KA'I '  1  N  G 


329 


ing. "  The  hot  water  in  the  system  will  maintain  a  good  "'night 
temperature,"  whereas  with  steam  heat,  when  the  fires  are  banked 
the  pressure  goes  down  and  the  building  quickly  cools.  Hot  water, 
however,  will  probably  never  wholly  replace  steam,  and  the  illus- 
tration of  apparatus  and  methods  for  both  systems  will  therefore 
be  given. 

HOT  WATER  HEATING. 

There  are  three  methods  of  heating  by  hot  water.  The  first 
of  these  is  the  Overhead  Low  Pressure  Gravity  system.  Ln  this 
system  the  water  is  carried  to  the  attic,  the  highest  point  oL'  the 
apparatus,  by  convection.    From  this  point  it  returns  in  all  pipes 


fig.  196. 
Hot  water  heating.     One  pipe  circuit  system. 

into  a  main  return,  which  is  in  the  basement,  and  which  runs  to 
the  boiler  (Fig.  195).  The  second  and  third  systems  are  known 
as  basement  or  direct  systems,  the  second  the  one -pipe  and  the 
third  the  two-pipe  system.  In  the  one-pipe  system,  one  large  main, 
or  one  main  and  several  sub-mains,  are  run  around  under  the  base- 


330 


VENTILATION   AND  HEATING 


ment  ceiling.  The  hot  water  connections  to  radiators  are  taken  off 
the  top  of  the  main,  the  water  returning  into  the  side  of  the  same 
main  (Fig.  196). 

In  the  direct  system  the  water  rises  from  a  horizontal  main 
into  the  several  branches  and  returns  in  others,  which  empty  into 
a  main  return  in  the  basement,  which  conveys  the  water  back  to 
the  boiler.  Fig.  197  shows  such  a  system.  In  the  latter  system  it 
is  necessary  to  place  air  valves  on  the  radiators.  These  must  be 
opened  when  they  become  "air  bound,"  which  they  do  owing  to 
the  fact  that  hot  water  expands,  and  when  it  cools  contracts  again 
to  normal,  leaving  air  in  the  tops  of  the  radiators,  which  must  be 


FIG.  197. 
Hot   water   heating.     Two   pipe    system. 

expelled  before  they  will  again  fill.  Fig.  198  shows  this,  as  also 
the  air  valve. 

In  both  systems  an  expansion  tank  is  necessary,  so  that  the 
excess  of  water  under  its  expanded  condition  will  still  remain  in 
the  apparatus  when  it  cools. 

In  the  overhead,  or  gravity,  system,  no  air  valves  are  neces- 
sary, as  all  the  air  rises  to  the  highest  point,  as  can  be  seen  by 
the  illustrations,  and  is  discharged  from  the  expansion  tank,  which 


YK  X  I  ILATION   AND   HEATING 


331 


is  placed  above  the  highest  point  of  the  main  riser.  In  the  direct 
.system  an  air  vent  is  put  into  the  expansion  tank  to  equalize  the 
pressure.  An  overflow  pipe  from  the  expansion  tank  in  both  sys- 
tems should  be  returned  to  the  boiler  room,  so  as  to  indicate  the 
height  of  the  water  under  ordinary  circumstances  without  the 
necessity  of  consulting  the  water  glass  which  is  put  on  the  tank. 


fig.  198. 
Valves. — All  valves  used  in  hot  water  work  to  turn  the  heat 
off  or  on  should  be  of  what  is  known  as  the  "quick  closing"  pat- 
tern— namely,  those  which  with  either  a  quarter  or  a  half  turn  of 
the  wheel  will  close  or  open  the  water  flow.  All  such  valves  should 
be  selected  with  extreme  care,  as  the  difference  in  cost  between 


fig.  199. 

the  best  types  and  those  which  are  not  entirely  dependable  is  so 
slight  thai  it  should  not  he  taken  into  consideration. 

In  the  direct  system  it  will  be  necessary,  as  stated,  to  put  in 

air  vents.    These  can  I f  either  the  handle  type,  or  those  which 

are  operated  with  ;i  key  which  can  be  removed  and.  so  preveni 
tampering  with  the  valves.  As  in  other  valves,  these  air  valves  or 
vents  should  be  selected  with  the  utmost  care,  and  it'  they  are  of 


332  VENTILATION   AND    HEATING 

the  automatic  type,  they  should  have  a  composition  seat  over  the 
air  vent  which  will  prevent  any  leakage  of  water  (Fig.  199). 

Piping.— If  the  system  is  on  the  "how  Pressure  Gravity," 
the  main  riser  must  be  properly  supported,  so  that  there  will  be 
no  settlement  whatever  in  the  pipe.  Jt  must  also  be  so  placed, 
and  the  extensions  from  it  taken  off  in  such  a  manner,  that  there 
will  be  allowance  for  expansion  and  contraction  without  injuring 
any  joints  or  causing  any  leaks.  From  the  main  riser,  as  shown 
in  the  drawing,  the  mains  are  run  in  the  attic,  all  proportioned  to 
the  proper  size,  and  none  of  these  pipes  must  fall  in  the  direction 
in  which  the  water  will  travel  less  than  one  inch  in  every  ten  feet. 
It  might  be  Mated  here  also  that  no  pip"  in  any  hot  water  heating 
plant  should  be  less  than  one  inch  inside  diameter. 

In  direct  systems  the  same  care  must  be  exercised  in  the  run- 
ning of  all  horizontal  mains,  and  the  only  difference  between  over- 
head and  the  direct,  so  far  as  piping  is  concerned,  is  that  both 
supply  and  return  are  in  the  basement  in  the  latter.  The  size  of 
all  mains  in  both  systems,  .is  well  as  all  other  pipes,  must  be  care- 
fully calculated,  this  depending  upon  the  amount  of  radiation  sup- 
plied, distance  of  travel  of  the  water  ami  directness  of  travel 
i.  .'.,  number  of  bends  or  turns.  In  the  hanging  of  pipes  they 
should  be  supported  not  less  than  every  ten  feet  on  the  horizontal 
runs,  and  the  hangers  for  these  should  be  so  arranged  as  to  take 
care  of  the  expansion  and  contraction  in  the  mains. 

Thermometers  and  Gauges. — In  both  systems  there  should 
be  placed  in  the  flow  and  return  accurate  contact  thermometers. 
The  object  of  putting  in  two  of  these  will  be  explained  later.  An 
altitude  gauge  to  register  the  height  of  the  water  should  also  be 
provided  in  the  outgoing  main.  As  stated  above,  the  ''tell  tale" 
from  the  expansion  tank  would  supplement  this  gauge  in  indicat- 
ing the  heighl  of  the  water  in  the  system,  as  it  would  overflow 
when  the  system  was  full. 

Expansion  Tank. — The  expansion  tank,  as  stated,  is  always 
placed  somewhat  above  the  highest  point  of  the  highest  pipe  in 
the  system,  and  should  be  provided  with  a  gauge  glass  to  indicate 
the  height  of  the  water.  It  is  somewhat  better,  and  is  recom- 
mended wherever  it  is  possible  to  do  so,  to  run  the  feed  or  supply 
pipe  which  fills  the  apparatus  to  this  expansion  tank,  rather  than 
directly  into  the  boiler,  as  the  cold  water  which  is  put  into  the 
system  will  he  heated  before  it  reaches  any  part  of  the  apparatus 
which  directly  contributes  heat  to  the  building.  From  the  tank 
there  should  also  be  a  circulating  and  overflow  pipe,  and  a  return 
Overflow  to  the  boiler  room.  It  is  necessary  also  to  place  either  an 
aii-  vent  on  this  tank,  or  better  still,  a  safety  and  vacuum  Valve. 


VENTHjATION  AND  HEATING  •>•)•> 

Temperature. — The  entire  system  for  hot  water  heating 
should  be  so  designed  that  the  inside  temperature  and  the  outside 
temperature  are  the  basis  upon  which  the  calculations  should  be 
made.  That  is  to  say,  if  the  temperature  of  the  room,  aside  from 
special  cases,  is  to  be  70  degrees  when  the  external  temperature 
is  10  degrees  below  zero,  there  should  be  sufficient  radiation  and 
boiler  capacity  so  that  the  temperature  of  the  water  as  it  leaves  the 
boiler,  as  indicated  on  the  outgoing  thermometer,  should  not  be 
more  than  190  degrees.  The  difference  between  the  temperature 
of  the  water  as  it  leaves  the  boiler,  and  as  it  returns  to  the  boiler, 
after  going  through  the  entire  system,  as  indicated  on  the  ingoing 
thermometer,  which  is  placed  on  the  return  at  the  boiler,  should 
not  be  more  than  15  degrees.  It  is  to  be  seen  from  this  that  any 
two  points  of  maximum  and  minimum  temperature  can  be  taken, 
and  it  will  only  be  necessary  to  so  design  the  entire  system  that 
this  will  naturally  result. 

The  object  in  doing  this  is  not  a  saving  on  the  primary  cost 
so  much  as  it  is  a  saving  on  the  yearly  expenditure,  year  in  and 
year  out,  so  long  as  the  institution  stands.  Fifteen  degrees  is  a 
good  working  basis  between  maximum  and  minimum,  with  from 
10  to  20  degrees  below  zero  as  the  outside  temperature. 

In  general  the  main  object  to  be  reached  in  the  installation  of 
a  hot  water  heating  apparatus  is  to  have  sufficient  capacity  in  all 
of  its  parts,  a  quiet  and  positive  working  system  throughout,  and 
economy  at  the  boilers  when  once  the  system  is  installed. 

STEA^I  HEATING. 

Steam  heating  was  formerly  divided  into  two  classes — high 
pressure  and  low  pressure.  High  pressure  steam  heating  is  a 
system  of  the  past  except  in  very  isolated  cases.  High  pressure 
steam  has  to  do  now  almost  entirely  writh  power.  Such  steam 
from  the  power  plant  as  is  used  for  heating  purposes  first  passes 
through  a  pressure  reducing  valve  and  is  allowed  to  pass  into 
the  heating  system  at  a  pressure  of  from  two  to  five  pounds  only. 

Steam  heating  may  be  classified  as  Low  pressure  and  vacuum. 
Low  pressure  steam  is  designated  by  the  system  of  piping  used 
for  its  conveyance.  To-day  we  have  the  overhead  or  Mills  system, 
the  two-pipe  system,  the  one-pipe  system,  and  the  single-valve 
system.  This  last  system  has  several  subdivisions,  such  aa  the 
continuou  circuit,  the  wet  and  dry  return,  etc.  We  will  consider 
simply  the  single-pipe  or  valve  system. 

The  overhead  or  Mills  system  consists  of  a  main  riser  to  the 
top  of  the  building,  laterals  above  the  highest  radiators  distribut- 
ing the  steam  to  the  radiator  risers  with  corresponding  branches 


334 


VENTILATION   A  X  i »   HEVI'IXG 


cither  on  basement  ceiling'  or  below  the  basement  floor.  Branches 
for  the  radiators  are  taken  out  from  the  riser  below  the  floor  line 
at  the  radiator.  This  system  is  very  useful  in  large  hospitals,  or 
those  having  very  little  height  in  basement  for  suitable  pitch  of 
the  main  pipes. 

The  two-pipe  system  is  one  that  has  been  adopted  for  many 
years,  though  not  now  in  general  use.  It  consists  of  a  separate 
main  at  basement  ceiling  with  corresponding  return  at  or  below 
basement  floor.  Each  radiator  is  equipped  with  two  valves,  one 
for  supply  and  one  for  return.  The  supply  comes  from  main  at 
basement  ceiling,  and  the  return  enters  the  main  return  at  or 
below  the  basement  floor.  Into  this  return,  also  at  frequent  inter- 
vals, is  connected  a  branch  from  the  main  steam  pipe,  which  acts 
as  a  bleeder  or  drip  for  conducting  the  water  from  the  steam  main 


FIG.  200. 
Low  pressure  steam  heating.     One  pipe  gravity  return. 

back  to  the  boiler.  In  this  system  the  main  steam  and  main  return 
pipes,  also  the  risers  to  and  from  the  radiators,  may  be  of  smaller 
size  than  are  used  in  the  single-pipe  or  single- valve  system.  The 
double  pipe  system  has  one  advantage  over  the  single-valve  sys- 
tem. By  its  use  the  valves  may  be  partially  opened  without  caus- 
ing the  hammering  noise  noticeable  in  the  other  system  when 
valves  are  not  entirely  closed  or  opened.  Its  expense  and  the  con- 
siderable cutting  necessary  for  its  installation  are  against  it, 
though  it  must  still  be  used  where  indirect  radiation  is  wanted. 
The  one-pipe  system  is  nearly,  if  not  quite,  obsolete.  It  con- 
sisted of  one  pipe  run  from  top  of  boiler  to  the  radiator,  the  boiler 
being  the  low  point,  so  that  the  steam  and  water  of  condensation 


VENTILATION  AND  HEATING  660 

traveled  in  opposite  directions  in  the  same  pipe,  which  of  necessity 
was  of  large  diameter  comparatively.  This  system  was  used  very 
extensively  in  connection  with  the  old  sheet  iron  radiator  (Fig. 
200). 

The  single-valve  system  is  the  one  most"  in  use  at  the  present 
time,  having  steadily  gained  favor  since  about  1880.  In  con- 
struction it  is  the  reverse  of  the  single-pipe  system  (though  often 
misnamed  the  single-pipe  system).  The  high  point  in  the  main 
pipe  is  at  the  boiler.  The  main  pipe  may  be  what  is  known  as  a 
continuous  circuit,  in  which  case  it  starts  high  at  boiler,  gradually 
falling  as  it  passes  around  the  basement  back  to  the  boiler,  where 
it  abruptly  drops,  entering  the  boiler  at  the  bottom.  The  water 
and  steam  in  the  main  travel  in  the  same  direction.-  The  laterals 
or  branches  to  the  radiators  are  taken  from  the  top  of  the  main 
and  the  pitch  is  from  the  radiator  to  the  main,  the  water  and  the 
steam,  as  in  the  single-pipe  system,  thus  traveling  in  reverse  di- 
rections only  in  the  branches  to  the  radiators.  The  philosophy  of 
the  single-valve  system  lies  in  the  fact  that  the  transverse  area 
of  its  one  pipe  and  one  valve  equal  nearly  the  transverse  area  of 
the  two  pipes  and  the  two  valves  of  the  two-pipe  system.  A> 
before  stated,  it  is  very  necessary  that  the  valves  on  the  radiators 
of  this  system  should  be  operated  intelligently,  as  a  valve  opened 
partially,  while  permitting  the  steam  to  enter,  will  not  permit  the 
water  (the  result  of  the  condensation  of  steam)  to  return  to  the 
boiler.  The  least  that  can  happen  under  these  conditions  is  a  very 
considerable  noise  in  the  radiator  when  the  valve  is  opened  until 
the  water  leaves  the  radiator. 

Valves. — The  radiator  valves  should  be  of  the  best  quality, 
and  of  such  a  type  as  has  absolutely  been  proven  to  be  effecti\.\ 
and  under  all  circumstances  these  valves  should  be  supplied  with 
a  Jenkin's  disc.  The  air  valves  on  the  radiators  can  be  one  of  the 
several  types  mentioned,  but  the  entirely  automatic  valve  is  not 
to  be  recommended.  There  should  be  some  form  of  adjustment  on 
every  valve,  so  that  the  condition  existing  can  be  met,  and  the  air 
escape  should  not  depend  upon  a  general  condition.  Valves  are 
now  to  be  obtained  made  in  such  a  manner  that  from  the  air  venl 
of  these  valves  there  is  a  small  pipe  which  is  run  out  of  the  room, 
so  that  the  odors  usually  accompanying  the  discharge  of  the  air 
from  the  radiators  is  entirely  overcome.  Air  valves  are  usvd  on 
all  radiators  in  steam  heating. 

The  effective  working  of  these  valves  depends  upon  the  ex- 
pansion of  a  metal  drum,  which  closes  the  air  vent  when  this  drum 
expands  under  the  action  of  the  heat  of  the  radiator.  This  per- 
mites  of  the  cold  air  in  the  radiator  being  expelled,  and  as  soon  as 


336 


VENTILATION  AND  HEATING 


the  radiator  becomes  hot  the  drum  expands  as  stated  and  closes 
off  the  .-.-ape  (Fig.  201). 

The  thorough  cleaning  of  the  strain  heating  apparatus  before 
permanent  air  valves  are  placed  cannot  be  too  greatly  emphasized. 
Even  in  a  well-constructed  apparatus  oil  and  sand  will  cause 
faulty  working. 

Piping.— The   area   of  the  main  pipe  in   steam-heating  work 


FIG.  201. 


T 


must  be  equal  in  capacity  in  every  ease  to  that  of  all  of  the  branch 
pipes  taken  off  this  main.  As  its  distance  from  the  boiler  be- 
comes greater,  it  may  consequently  be  reduced  in  size,  but  the  de- 
n-eased pipe  must  follow  the  same  rule  as  applies  to  auxiliary 
pipes.  It  is,  however,  more  economical  to  run  the  main  full  size 
than  to  fit  it  with  reducing  fittings. 

Temperatures.— The  temperature  of  rooms  ordinarily  is  68 


VENTILATION   AND   HEATING  331 

to  72  degrees,  and  this  follows  closely  for  the  entire  hospital.  As 
in  all  other  systems  of  heating,  the  calculation  for  the  entire  work 
should  be  based  on  the  difference  between  these  inside  tempera- 
tures and  the  outside  temperatures.  There  should  be  sufficient  radi- 
ation and  boiler  capacity  so  that  when  the  outside  temperature  is 
10  degrees  below  zero  and  with  a  given  pressure  at  the  boiler, 
which  in  the  above  case  should  not  exceed  three  pounds,  the  tem- 
perature of  the  rooms  should  be  maintained  with  a  free  circulation 
in  all  parts  of  the  apparatus,  without  noise  attending  this  circu- 
lation. 

In  general  the  main  object  in  the  installation  of  a  steam- 
heating  plant,  of  whatever  pattern  or  system  it  may  be,  is  that 
there  be  sufficient  capacity  in  all  of  its  parts  to  insure  a  quiet  and 
positive  service  throughout  with  an  attendant  economy  at  the  boil- 
ers when  once  the  system  is  installed. 

VACUUM  HEATING. 

Vacuum  heating  is  properly  divided  into  two  classes,  the 
mechanical  system,  which  utilizes  the  waste  product  of  the  power 
plant — i.  e.,  the  exhaust  system — -and  the  mercury  or  seal  system, 
which  is  adapted  to  the  low-pressure  heating  plant. 

The  principle  of  the  mechanical  vacuum  system  is  to  remove 
the  air  from  the  heating  apparatus  by  means  of  a  pump  and 
ejector  or  similar  device.  As  all  resistance  is  removed,  exhaust 
steam  circulates  as  positively  as  would  steam  under  pressure.  In 
case  there  is  not  sufficient  exhaust  steam  for  the  purpose  of  heat- 
ing, the  deficiency  is  made  up  by  permitting  live  steam  to  enter 
the  system  through  a  pressure-reducing  valve,  which  is  a  part  of 
the  apparatus.  Pumping  the  exhaust  steam  from  the  cylinder  of 
the  engine  removes  all  liability  of  back  pressure.  This,  together 
with  the  fact  that  exhaust  steam  was  formerly  practically  a  waste 
product,  leaves  no  doubt  that  the  economical  operation  of  power 
plants  demands  a  vacuum  apparatus.  It  has  truthfully  been  re- 
marked that  a  large  building  using  power  could  be  operated  at 
less  fuel  expense  in  the  winter  when  the  heating  apparatus  is  in 
use  than  it  could  be  in  the  summer  when  the  heat  is  turned  off. 
This  is  due  to  the  fact  that  the  engine  is  relieved  entirely  of  hack 
pressure.  Where  there  is  no  steam  power  plant  from  which  ex 
haust  steam  may  be  taken,  the  low-pressure  vacuum  system  is  best 
adapted,  it  being  evident  that  the  expense  of  the  power  necessary 
to  operate  the  mechanical  exhauster,  of  whatever  nature,  would 
equal,  if  it  did  not  exceed,  any  saving  that  could  be  effected  by  the 
use  of  vacuum  apparatus.  This  fact  is  generally  recognized  by 
manufacturers  of  mechanical  vacuum  heating  apparatus. 


338  VENTILATION  AND  HEATING 

In  low-pressure  vacuum  heating  apparatus  a  gauge  is  used 
to  indicate  results  obtained.  Most  all  users  of  low-pressure  steam 
heating  having-  compression  air  valves  have  noted  from  time  to 
time  that  after  a  radiator  was  heated  and  the  air  valve  closed  that 
the  radiator  retained  the  heat  for  a  considerable  time  after  pres- 
sure at  the  boiler  had  subsided.  Many  attempts  have  heen  made 
to  perfect  an  automatic  air  valve  to  accomplish  this  very  much 
desired  result,  but  with  poor  results.  Some  of  these  valves  are 
still  on  the  market.  The  fact  is  that  a  valve  for  this  is,  by  the 
nature  of  the  work  it  is  expected  to  accomplish,  subject  to  constant 
and  rigid  wear,  with  the  result  that  it  rapidly  deteriorates,  and 
after  a  short  time  parts  of  it  must  be  renewed.  This  fault,  to- 
gether with  the  fact  that  air  expelled  from  a  hearing  apparatus 
into  rooms  is  very  undesirable  from  a  sanitary  viewpoint,  has 
led  to  the  revival  of  a  very  old  method,  that  of  running  air  pipes 
from  the  radiators  into  the  basement,  connecting  them  together 
and  immersing  them  in  a  mercury  seal. 

Vacuum  is  obtained  in  this  system  by  first  raising  pressure 
to  expel  the  air  from  the  apparatus,,  the  purpose  of  the  seal  being 
to  prevent  its  return.  By  this  means  the  boiling  point  of  water  is 
lowered,  which  must  be  admitted  to  be  a  very  desirable  increase 
to  the  range  of  temperatures  at  which  a  steam  plant  may  be  oper- 
ated, especially  serviceable  in  the  milder  months  of  early  fall  and 
late  spring.  Actual  comparative  tests  using  the  same  heating 
planl  with  and  without  vacuum  attachments  have  shown  a  fuel 
economy,  an  item  worthy  of  consideration  in  the  operation  of 
even  the  smallest  heating  plant.  The  manner  of  piping  also  pre- 
cludes the  possibility  of  damage  to  floors  or  ceilings  by  leakage, 
an  advantage  not  to  be  overlooked. 

Tt  must  be  borne  in  mind  that  the  above  description  refers 
to  a  tight  plant.  In  ordinary  practice  a  plant  that  will  draw  from 
fifteen  to  twenty-eight  inches  of  vacuum  is  easily  within  the  possi- 
bilities. 

To  work  perfectly  a  vacuum  system  must  be  perfect  in  every 
detail.  Thus  far,  except  in  a  few  instances,  perfection  has  not 
been  obtainable,  and  this  only  in  such  measure  as  to  warrant  the 
belief  thai  vacuum  heating,  except  in  high-pressure  work,  will 
need  much  study  before  it  can  be  universally  used. 


CHAPTER  XIX. 

IRON. 

The  use  of  structural  iron  and  steel  in  buildings  depends 
wholly  upon  the  design  of  the  building,  the  system  of  fireproofing 
which  is  to  be  used,  the  weight  of  the  loads  which  come  on  the 
floors,  and  a  number  of  other  considerations. 

All  structural  shapes  must  necessarily  be  figured  out  for  the 
loads  which  they  are  required  to  carry.  Their  general  character  as 
to  shape,  size,  weight  and  length  of  span  all  depend  upon  this  one 
item.     If  the  building  has  supporting  columns,  or  if  it  is  of  the 
skeleton  steel  construction- -that  is,  a  building  entirely  of  struc- 
tural steel  incased  in  brick,  tile  or  stone— the  sizes  of  the  mem- 
bers of  the  structure  from  foundation  to  roof  must  be  made  care- 
fully for  that  form.    If  it  is  of  the  form  as  shown  in  Fig.  .!,  with 
all  supporting  walls,  but  few  structural  shapes  are  necessary.     If 
in  such  a  building  reinforced  concrete  floors  were  used  no  struc- 
tural shapes  would  be  required,  as  explained  under  Fireproofing. 
There  are  certain    structural     shapes  necessary,  however,  m  all 
buildings,  except  those  constructed  wholly  of  reinforced  concrete. 
The  following  description  of  such  iron  and  steel  work  is  not 
intended  as  a  specification  guide,  but  merely  to  give  a  comprehen- 
sive idea  of  the  use  of  steel  in  hospital  buildings.     Steel  for  rein- 
forced concrete  work  is  fully  explained  elsewhere,  so  that  only 
that  for  buildings  wherein  structural  shapes  are  required  will  be 
mentioned  herein. 

The  loads  to  be  carried  and  the  usual  factors  which  go  to 
make  up  the  construction  of  the  building  would  necessarily  have 
to  be  taken  into  account  for  the  sizes  and  shapes  of  (he  iron  to  be 
used.  The  manufacture  of  iron  in  tensile  strength  and  compre- 
hensive strength  are  matters  which  must  he  lel't  entirely  to  the 
engineer.  It  is  only  necessary  to  say  that  ail  wrought  iron  must 
be  of  a  ductile  and  fibrous  form;  that  all  shapes  musl  be  straight 
and  smooth  and  free  from  all  buckles,  blisters,  cracks  or  cinder 

pockets. 

Steel  and  cast  iron  also  should  he  of  the  besl  quality.  The 
latter  should  be  of  the  tough  gray  iron,  free  from  "coal  shuts"  or 
"blowholes,"  and  should  be  up  to  standard  requirements  for  ail 
of  the  work. 


340 


u;ox 


Setting. — The  setting  of  all  iron  and  steel  work  must  of  ne- 
cessity be  plumb  and  true,  and  must  be  properly  secured  in  posi- 
tion. Ordinarily  this  is  a  matter  of  design,  in  which  each  bolt  or 
rivet  is  shown,  but  it  is  well  to  mention  here  that  unless  the  work 
is  carefully  done  there  is  liability  of  failure  in  the  structure. 

Bolting  and  Riveting. — All  bolt  holes  in  the  cast  iron  should 
be  bored  so  that  the  bolts  iit  securely.  The  bolts  in  all  of  this 
work   should   have   wrought    iron   washers,  and  under  ail  circum- 


fig.  202 

stances  the  entire  threads  on  the  nuts  must  be  engaged  on  the 
bolt.  It  may  be  well  to  mention  here  that  bolts  are  not  as  good  as 
rivets  for  iron  and  steel  work,  and  their  number  should  be  at 
least  20  per  cent,  over  what  would  be  used  if  the  work  was  riveted. 
The  rivets  should  completely  fill  the  holes,  and  should  have  full 
hemispherical  heads,  concentric  with  the  shanks  of  the  rivets,  and 
wherever  practical  they  should  be  driven  by  machine. 


fig.  203. 

Bases. — Bearing  beams,  girders  and  the  bases  of  all  columns 
should  be  solidly  bedded  in  Portland  cement.  These  bases  are 
usually  flat  plates  on  the  walls,  or  plates  which  run  with  a  bevel  at 
the  edge  and  are  reinforced,  as  shown  in  Fig.  202,  for  columns. 
These  plates  are  ordinarily  designed  and  proportioned  so  that  the 
load  on  the  masonry  work  upon  which  they  come  does  not  exceed 
more  than  three  hundred  pounds  per  square  inch. 


IRON 


341 


Lintels. — Lintels  are  of  two  kinds,  the  east  iron  lintels,  some 
of  which  are  shown  in  Fig.  203,  and  the  simple  form  or  built-up 
form  of  wrought  iron  or  steel,  as  shown  in  Fig.  204.  These  lintels 
are  put  over  all  large  openings,  or  openings  with  square  heads, 
or  those  over  which  loads  may  come,  in  order  to  carry  the  masonry 
and  those  parts  of  the  structure  which  rest  upon  or  over  them. 


pig  204. 
In  ordinary  buildings  it  is  sometimes  sufficient  to  put  angle  irons 

over  the  windows,  which  will  carry  whatever  may  conic  over  them, 
and  to  throw  an  arch  on  the  inside,  as  shown  in  l\m\  205.  These 
lintels  should  all  have  a  bearing  on  the  wall  of  at  Least  six  inches 
at  each  end.     Tf  tliev  arc  casl  iron,  they  should  under  no  circum- 


342 


IROX 


stances  be  less  than  three-fourths  of  an  inch  thick  in  any  of  their 
parts. 

Cast  [roe  Columns.— If  cast  iron  columns  are  necessary  in 
the  building,  they  should  be  true  and  straight,  and  of  a  full  and 
uniform  thickness  for  their  entire  length,  and  all  necessary. brack- 
ets, flanges  and  other  connections  to  them  should  be  cast  on  them, 
as  in  ordinary  practice  hoi  ling  such  members  to  cast  iron  is  not 
to  be  recommended.  All  bolt  holes  in  these  columns  should  be 
drilled.  Xo  cast  iron  column  should  be  less  than  three-fourths  of 
an  inch  thick  at  any  point,  and  they  should  never  exceed  in  length 
twenty  times  their  least  diameter. 

Wrought  Iron  \.\i>  Steel  Columns. — These  should  be  in 
lengths  of  two  or  three  stories,  and  should  be  made  up  of  channels 

"1 


fig.  205. 
and  plates  so  arranged  as  to  form  a  symmetrical  column.  Figs. 
206,  207  show  columns  of  this  kind.  The  caps  and  base  of  these 
should  be  built  up  of  plates  and  angles  as  shown  in  Fig.  207.  Xone 
of  these  columns  should  have  a  length  exceeding  sixty  times  its 
least  width.  The  general  design  and  construction  of  such  columns 
are  left  entirely  to  the  engineer. 

Beams  and  Girders  jx  Steel  Constructed  Buildings.— The 
floor  construction  is  made  up  of  beams  and  girders.  The  girders 
are  the  members  which  run  from  column  to  column  and  catch  the 
beams,  the  latter  being  to  the  building  what  the  ordinary  joist  is 
to  a  wooden  constructed  floor.  The  beams  should  have  a  bearing 
of  at  least  eight  Inches  on  the  wails  wfyere  they  so  come,  and  should 
be  sel  either  on  the  beams  or  coped  on  the  beams  with  what  is 
known  as  "standard  connection  angles."  Fig.  208  shows  the 
coping  of  these  beams  on  to  the  girders. 

Box  and  Plate  Girders.  In  some  instances  it  is  not  expedient, 
and  in  others  ao1  possible,  to  get  beams  of  sufficient  strength  to 
carry  the  loads   which   come  upon   them.     In  such  cases  box  and 


IRON 


343 


plate  girders  are  built.  The  box  girder  is  shown  in  Fig.  209,  and 
a  single  web  rivet  girder  is  shown  in  Fig.  210.  There  are  so  many 
forms  of  both  of  these  girders  that  it  would  be  impossible  to  ex- 

mi 


Aopo  oi'op 
!oijoofl&|  . 

/o  jo;  o  o\\o\  o\ 

fig.  206. 
plain  them  all.    They  arc  d^igm-d  in  nil  of  Hum.-  members  to  carry 
the  loads  which  come  upon   them   respectively,  jusl   as  single   1 
beams  would  carry  them. 

In  box  girders  there  is  also  provision  made  for  wind  stresses, 
as  in  this  form  there  is  more  liability  to  collapse  than  in  a  single 
beam,  owing  to  the  shape  of  the  former. 

Trusses.— Trusses  arc  ordinarily   used   in   roofs,  and   are  of 


344 


IRON 


several  forms,  depending  entirely  upon  the  .slope  of  the  roof,  the 
span,  and  such  other  calculations  as  would  come  in  under  built-up 
forms.  They  are  composed  of  tension  members,  which  are  usually 
made  of  iron  bars,  and  compression  members  which  can  be  one  of 
many  forms,  but  arc  usually  made  of  angle  irons,  or  such  other 
shapes  as  would  be  necessary,  depending  upon  the  loads  to  be 
carried.  From  truss  to  truss  there  is  put  what  are  known  as 
"sway  rods,"  which  tie  the  trusses  together,  so  as  to  have  a  con- 
tinuous strain  in  any  given  direction:  these  rods  arc  so  arranged 
that  they  are  always  in  tension.     Fig.  211  shows  a  truss  with  the 


o    o 

O     ( 

D     O 

A 

o   o 

O     ( 

D     O 

fig.  207. 


Plan. 


Elevation. 


sway  rods.  These  trusses  are  all  built  so  as  to  allow  for  expan- 
sion and  contraction,  which  might  take  place  under  a  difference 
of  temperature.  Tn  such  instances  the  trusses  are  put  upon  bear- 
ing plates,  which  are  bolted  to  the  top  of  the  column,  or  to  the  top 
of  the  wall  upon  which  the  trusses  rest. 

Puelins. —  From  truss  to  truss  are  then  put  purlins,  which 
correspond  to  the  ordinary  roof  joist  in  ordinary  construction. 
These  purlins  ordinarily  are  single  angles  or  T  irons. 

Kiki.  K><  \i-Ks.  A>  mentioned  in  Fi reproofing,  fire  escapes  are 
of  many  kinds,  and  in  most  instances  those  which  are  used  in  hos- 
pital buildings  arc  constructed  according  to  the  requirements  of 
the  local  laws.  The  two  common  kinds  are  the  ladder  and  the  stair. 
There  are  other  forms  also,  such  as  the  continuous  rotary,  in  which 
persons  are  conveyed  to  the  ground  by  sliding  down  a  circular 


IROX 


345 


chute,  and  those  in  which  the  entire  ladder  or  stairs  move,  but 
these  will  not  be  considered  here. 

Fire  escapes  should  be  made  entirely  of  wrought  iron,  and 
have  balconies  properly  supported,  either  by  brackets  or  from 
floor  to  floor,  depending  upon  the  size  of  these.  When  balconies 
are  used,  they  necessarily  would  be  of  different  construction  than 
if  only  a  platform  were  provided.     The  size  of  the  members  of 


fig.  208. 

these  stairs  depend  entirely  upon  the  design,  the  length  of  the  runs. 
and  the  possible  loads  which  might  come  upon  them. 

Stairs. — In  the  chapter  on  Pireproofing  mention  was  made 
that  the  stairs  are  also  made  of  iron,  and  if  so  constructed  the 
stringers  should  not  be  less  than  2%x%  in.  iron  placed  double 
with  l%xl%x%  in.  lattice  bar  to  support  the  treads,  as  shown 
in  Fig.  — .  The  treads  are  of  cast  iron  and  should  have  checkered 
top  and  nosing  on  the  edge,  but  they  may  be  of  the  safety  tread 


1 

; 

r 

c 

) 

c 

) 

c 

3 

c 

) 

c 

3 

y 

)                       c 

k 

r^             r\          r^           <">       r^      o       r^       <^>       <~> 

r>    r\    o      i~i      <->      t 

O 

o^o 

o 
o 

o'o^o^o^o 

"5" 
o 

"o^o^o^d 

1 

o 

o 

0 

1 

o 

o 

0 

\ 

o 

o 

0 

o 

o 

0 

o 

\ 

o  o 

o^o^o^o^o 

QrPrPrA 

\J 

V-^ 

-^ 

\J        KJ       {J        VJ       \J        KJ 

o 

\J     VJ     <-> — ' 

fig   209. 

type,  or,  as  stated,  of  some  tonn  of  marble  or  stone.  The  risers 
maybe  of  the  latter,  but  if  the  stairs  are  entirely  of  iron,  the  riser- 
are  of  cast  iron  with  some  open  work  figure. 

Iron  Shutters.— I !'  iron  shutters  arc  used  on  the  windows 
the  frames  of  these  should  nol  be  constructed  of  loss  than  2x%  in. 
iron,  and  these  should  be  properly  covered.  The  matter  of  re- 
quirements for  these  is  usually  stipulated  by  the  local  ordinances, 
or  by  the  rules  of  underwriters,  so  thai  no  standard  can  be  given. 


346 


TRON 


The  shutter  eyes,  if  such  shutters  are  used,  should  be  built  in  when 
the  building  is  being  erected. 

The  iron  work  for  railings,  stairways  and  elevator  inclosures 
usually  depends  entirely  upon  the  amount  of  money  which  is  to 
be  expended  upon  them,  and  rests  largely  upon  the  design  desired. 
These  are  of  the  ordinary  wire  lattice  form,  the  flat  steel  ribbon 
form  or  of  built-up  wrought  iron  in  round  or  square  bars.  They 
arc  also  made  of  ornamental  cast  iron  or  broiize,  but  these  have  no 
advantage  over  the  simple  forms  except  from  an  ornamental  or 
artistic  standpoint. 

PREPARATION  OF  STEEL  FOR  PAINTING. 

The  main  requisite  for  all  metal  surfaces  is  their  proper  prep- 
aration for  protecting  them  from  corrosion.  Nothing  in  all  struc- 
tural steel  work  is  of  more  importance  than  this,  unless  it  be  their 
protection  to  prevent  such  corrosion  after  their  preparation.  The 
one  is  absolutely  dependent  upon  the  other,  for  the  best  paint  is  of 


nn 


JL 


W 


.     r>     n     <~, 

r> 

/->      r\      »~»      r\     r\      r\ 

O- 

*~> 

<"> 

y^o^o 

8 
O 

owovyo0owbw6wo 

C 

0 

o  o 

o 
o 

l  * 

O 

o 

o 

\ 

o 

0 

o 

0 

o 

o 

/ 

o 

o 

o 
o 

o 
9, 

p.oAo„ 

o^o^cuo^o^o^o 

o^o 

'      <J      KJ      <U    ^J    <U          \J       U      <J       W      ^J      O           <-<         ^J            VJ 

FIG.  210. 


little  use  if  the  cleaning  is  improperly  done,  and,  on  the  other  hand, 
poor  paints  and  poor  painting  are  of  no  consequence,  however 
dean  the  surface  may  be.  The  following  requirements  do  not 
apply,  however,  to  surfaces  subjected  to  great  heat.  They  must 
be  treated  in  a  wholly  different  manner. 

Mill  Scale. — These  small  scales  of  iron  formed  by  the  rolling 
of  the  shapes  while  hot  from  the  ingots  must  be  thoroughly  re- 
moved. Rust,  dirt,  grease  and  the  other  extraneous  substances  on 
the  surfaces  must  also  be  removed.  This  is  done  with  wire 
brushes,  sand  blast,  scrapers,  benzine,  etc.,  or  in  case  there  is  more 
than  fine  surface  rust,  such  rusty  parts  must  first  be  subjected  to 
the  flame  of  a  torch,  until  the  oxide  has  been  entirely  converted. 
In  using  brushes  for  removing  scale  and  rust,  no  larger  than  a  No. 
6  brush  should  be  used,  and  under  no  circumstances  should  the 
use  of  flat  brushes  be  allowed. 

After  the  cleaning  is  complete  the  priming  or  shop  coat  should 


ii:u.\ 


347 


be  applied  at  once.  The  steel  should  not  be  allowed  to  stand.  The 
paint  should  be  applied  thoroughly  and  no  painting  should  be 
done  by  machine.  The  paint  should  be  applied  in  a  smooth  and 
even  coat,  and  care  taken  that  all  joints  and  crevices  are  propel  Ly 
covered.  In  all  work  of  a  compound  nature — namely,  where 
shapes  are  put  together,  as  also  all  drilled  holes,  permanent  bolts 
and  riveted  work,  such  work  should  be  first  primed,  and  llii>  coat 
left  to  thoroughly  dry  before  the  members  are  assembled  or  put 
together. 

If  any  abrasion  of  the  prime  coat  occurs  in  the  handling, 
loading  and  erecting  of  the  work,  such  abrasions  must  be  thor- 
oughly recoated  and  left  to  stand  for  at  least  four  days  before  the 
final  or  field  coat  of  paint  is  applied.  If  any  rust  should  form  at 
these  abrasions,  it  must  be  thoroughly  removed  before  the  prim- 
ing is  done. 


fig.  211. 

Not  too  much  stress  can  be  laid  on  the  foregoing,  for  it  is,  as 
stated,  of  vital  importance  in  the  protection  of  the  structural  steel 
from  corrosion. 

When  the  steel  is  riveted  the  entire  work  should  he  given  two 
good  coats  of  paint,  or,  better  still,  three  good  coats.  Each  coat 
of  paint  should  be  allowed  to  stand  for  al  least  tour  days,  until  it 
is  perfectly  dry,  before  the  next  coat  is  applied.  The  same  care 
in  applying  each  coat  must  he  exercised  as  was  given  to  the  prim- 
ing or  shop  coat. 

There  will  be  points  in  the  work  where  deep  crevices  and  re- 
cesses are  formed.  These  should  he  tilled  with  Portland  cemenl 
and  allowed  to  become  thoroughly  dry  before  the  held  coats  of 
paint  are  applied  to  them,  li  would  be  well  to  treat  such  cement 
with  a  waterproofing  compound,  such  as  was  mentioned  in  the 
chapter  on  Concrete.    This  work  must  be  done  carefully  and  thor- 


348  iron 

oughly,  as  these  crevices  and  deep  recesses  are  the  points  which 
would  admit  or  retain  water. 

No  painting  should  be  done  on  wet  or  frost)   surfaces,  nor  in 

a  temperature  lower  than  32  degrees  F.  All  priming  should  be 
done  under  cover,  and  ao  retouching  done  until  the  steel  is  erected, 
unless  it  can  be  done  immediately  upon  arrival  of  the  steel  at  the 
building.  Abrasions  caused  by  erection  should  be  primed  imme- 
diately after  the  steel  is  in  permanent  position.  The  painting  of 
steel  should  in  all  instances  lie  done  with  materials  which  contain 
no  artificial,  so-called  boiled  linseed  oils,  drying  oils,  japans,  driers 
and  naphtha,  as  all  of  these  are  injurious  to  the  paints  and  de- 
teriorate rapidly. 

Painting  of  Steel.-  -There  are  many  so-called  preservative 
paints  for  the  treatment  of  steel,  and  the  utmost  care  must  be 
taken  that  these  are  perfectly  adapted  to  this  class  of  work  before 
they  are  used. 

Paints  for  steel  and  iron  are  of  two  kinds — those  in  which 
pigments  of  one  kind  or  another  are  ground  into  linseed  oil,  and 
the  so-called  chemical  paints  which  are  in  the  nature  of  carbon 
products  chemically  treated. 

There  always  has  been,  and  probably  always  will  be,  a  vast 
difference  of  opinion  as  to  the  best  method  and  best  paints  to 
use  for  the  protection  of  metal.  This  may  be  due  in  part  to  the 
fact  that  under  various  conditions  the  same  pain!  will  at  different 
times  show  different  results.  The  direct  consequence  of  this,  irre- 
spective of  individual  opinion,  has  been  the  manufacture  of  dif- 
ferent kinds  of  paints,  with  different  ingredients  and  different 
methods  of  mixing  these.  It  is  safe,  therefore,  to  use  only  such 
products  as  have  been  found  to  give  the  greatesl  satisfaction  ami 
best  results  in  the  largesl  number  of  instances.  It  is  the  object*, 
therefore,  of  this  section  to  explain  the  different  kind.-  d'  paints 
as  concisely  as  possible,  giving  them  in  the  order  of  the  results 
obtained  rather  than  in  the  order  of  preference.  The  paints  are 
as  follows: 

h     Those  made  of  [>ure  graphite  and  boiled  linseed  oil. 

II.  Those  of  pure  graphite  with  other  inert  materials  and 
Linseed  oil. 

III.  Carbon  paints. 

IV.  Taints  for  resisting  acids,  gases  and  the  fumes  of  these. 

V.  Paints  on  surfaces  subjected  to  great  heat. 

VI.  Those  with  a  graphite  base,  but  made  in  colors. 

VI  L    Paints  with  a  red  lead  color,  bu1  containing  only  a  small 
percentage  of  red  lead. 
VIII.     Red  lead. 


IRON 


349 


The  Fallacy  of  "Thick  Coat"  Painting.— Certain  engineers, 
from  a  theoretical  standpoint,  have  considered  a  thick  coal  essen- 
tial to  good  painting.    The  contrary  is  the  truth,  as  borne  out  in 
practice.     The  more  a  coat  of  paint  is  brushed  out  and  properly 
covers  the  surface  the  better  will  be  the  results  of  drying,  and  the 
more  fit  will  that  coat  be  to  receive  and  hold  succeeding  coats.     A 
thick  paint  film  will  of  necessity  cause  trouble  to  itself  and  to  sue 
ceeding  coats,  which  will  not  become  thoroughly  knit  together,  will 
not  form  a  homogeneous  coating,  and  with  the  contraction  and  ex- 
pansion of  metal  are  bound  to  crack  badly.    This  is  true  whether 
the  thick  coat  results  from  the  "flowing  on"  of  a  paint  capable  of 
better  spreading  or  from  a  paint  of  poor  opacity  that  can  only 
uuver  by  using  a  heavy  coat.    If  the  paint  has  the  proper  opacity 
and  can  be  thoroughly  brushed  out  for  the  first  coat  and  1  unshed 
into  the  surface,  it  will  get  a  firmer  hold  on  it,  fill  its  pores  better 
and  make  a  more  satisfactory  protection  to  the  metal  as  well  as 
a  better  foundation  for  the  coats  to  follow. 

The  first  requisite  of  all  paints  of  the  pigment  variety  for  the 
proper  protection  of  metal  surfaces  is  that  these  be  made  of  prop- 
erly treated  linseed  oil  and  the  combination  of  the  pigments  with 
this.  The  linseed  oil  must  be  pure,  thoroughly  so,  in  fact,  and  not 
in  name  only.  It  must  contain  no  albumen,  mucilaginous  matter 
and  other  perishable  constituents,  as  these  ingredients  are  harm- 
ful and  hasten  decay  when  left  in  the  oil.  Linseed  oil  with  these 
deleterious  substances  removed  is  increased  in  its  drying  quali- 
ties, and  makes  it  possible  to  eliminate  driers  and  japans  which 
are  harmful  to  paint.  All  linseed  oil  should  be  thoroughly  aged, 
as  the  ordinary  method  of  filtration  will  not  give  the  quality  to  the 
paint  that  aging  does:  All  paints  should  be  machine  mixed. 
Paint  in  paste  form  cannot  be  mixed  by  hand  as  thoroughly  as  it 
can  be  done  by  machine. 

1.  Graphite  paint,  as  its  name  implies,  is  made  from  graphite 
pigment.  The  natural  graphite  paint  contains  only  from  15  to  60 
per  cent,  of  the  pigment.  The  best  form  is  graphite  produced  in 
an  electrical  furnace,  and  is  superior  to  the  graphite  which  is 
found  in  nature  in  one  of  two  forms— the  flake  and  the  amorphous. 
The  flake  graphite  does  not  make  a  good  paint  on  account  of  its 
flake  or  splinter-like  structure,  which  prevents  il  I'rom  combining 
thoroughly  with  the  oil  when  pn1  on  the  surfaces  of  metal.  The 
amorphous  form,  while  it  can  be  finely  -round,  is  found  with  such 
a  vast  number  of  impurities  mixed  in  with  it,  such  as  silica.,  clay 
and  other  foreign  matters,  that  it  has  little  value  as  a  pigment 
.  for  paints.  Both  of  these  natural  graphites  preclude  the  possi- 
bility  of   uniformity    in    the   paint.      The     artificially      produced 


350  IRON 

graphite  can  be  ground  to  an  impalpable  powder  and  is  so  finely 

divided  that  it  mixes  readily  with  the  linseed  oil,  forming  an  even, 
homogeneous  coating  when  applied  and  makes  a  95  per  cent,  pure 
graphite  paint. 

Pure  graphite  paints  arc  never  colored.  Natural  graphite  is 
a  dull  black,  and  any  coloring  matter  which  is  put  into  it  must  be 
a  very  targe  proportion  of  the  paint.  Red  oxide,  chrome  yellow 
or  other  colors  materially  displace  the  graphite,  thus  Lessening  the 
protective  value  of  the  paint. 

2.  Paints  of  this  character — namely,  those  which  contain 
pure  graphite  with  other  inert  materials  well  mixed  in  linseed  oil 

should  contain  about  60  per  cent,  of  pure  graphite,  and  of  the 
remainder  the  principal  part  should  be  silica.  This  proportion 
would  then  contain  about  the  same  amount  of  graphite  as  is  used 
in  the  best  natural  graphite  paints.  Under  such  circumstances  this 
paint  has  many  of  the  good  qualities  of  pure  graphite,  being 
largely  composed  of  the  same  pigments.  The  real  difference  in 
the  paint  is  in  the  more  rapid  drying  qualities  of  this  form. 

It  is  made  primarily  to  meet  special  conditions — namely,  that 
there  must  be  rapid  drying  with  a  hard  surface.  It  is  this  latter 
quality — the  rapid  and  harder  drying-— which  sacrifices  to  some 
extent  the  durability  of  the  paint,  but  it  is  not  of  such  great  im- 
portance that  it  need  be  considered  seriously.  Driers  are  neces- 
sarily put  into  this  paint,  but  if  they  contain  no  gums  and  are  made 
on  a  linseed  oil  base,  there  is  no  deleterious  effect  on  the  surface 
of  the  metal.  It  may  be  said  in  connection  with  this  form  of 
metal  paint  that  where  there  is  liability  to  abrasion  it  is  superior 
to  the  softer,  slower  drying  pure  graphite  paint.  Owing  to  the 
fact  that  this  paint  is  not  a  pure  graphite,  it  can  also  be  made 
in  gray. 

3.  The  so-called  ''carbon  paints"  are  ordinarily  chemical, 
inert,  metal  protectors  made  on  a  charcoal  base;  the  charcoal  is  in 
a  powder  pigment  form. 

4.  The  non-corrodible,  acid-resisting  paints  are  chemical 
combinations  for  the  protection  of  metal  surfaces  subjected  to 
the  corrosive  action  of  gases,  acids  or  their  fumes.  It  is  also  a 
protection  against  salt  water. 

5.  The  fact  that  graphite  paint  i^  not  adaptable  under  an> 
circumstance  where  the  metal  surface  is  to  be  subjected  to  heat 
has  given  rise  to  the  need  of  a  protective  paint  for  such  purposes. 
While  such  paints  do  not  ordinarily  pertain  to  iron  construction, 
they  are  nevertheless  used  to  some  extent  in  the  painting  of  pipes, 
boiler  fronts  and  smoke  stacks.     They  are  made  so  that  they  will 

stand  extreme  heat  without  blistering,  scaling  oi  cracking. 


IRON  '.W)i 

6.  Owing  to  the  fact  that  there  has  been  a  doubl  at  times  as 
to  the  proper  application  of  the  pigment,  and  the  specified  number 
of  coats  of  this  which  should  be  put  on  iron,  the  subject  of  a  paint 
with  a  graphite  base  to  be  made  in  different  colors  naturally  arose. 
It  is  absolutely  impossible,  however,  to  produce  red,  gray,  green 
and  other  variations  from  the  dull  black,  without  combining  some 
coloring  matter,  such  as  iron  oxides,  chrome  yellow,  etc.,  as  men- 
tioned, which  cannot  fail  to  weaken  the  protective  character  of  the 
pigment.  As  can  be  readily  seen,  it  would  require  a  very  large 
percentage  of  coloring  matter  to  turn  the  black  into  a  red,  gray  or 
green.    The  use  of  such  paints  is  not  recommended. 

7.  Paints  with  red  lead  color  are  a  substitute  for  pure  red 
lead  of  the  same  color.  They  contain  a  much  smaller  percentage 
of  red  lead  and  for  that  reason  do  not  have  the  high  oxidizing 
qualities  that  the  pure  red  lead  possesses.  For  this  reason  alone 
they  are  to  be  recommended  rather  than  the  latter.  The  fact  that 
such  paint  has  a  lighter  specific  gravity  than  the  pure  red  lead 
prevents  a  rapid  settling  and  hardening,  and  counteracts  the  ten- 
dency to  crawl  and  run,  both  of  which  are  such  great  drawbacks 
to  the  use  of  pure  red  lead. 

8.  The  use  of  red  lead  as  a  protective  paint  for  metal  sur- 
faces has  been  steadily  decreasing,  as  the  efficiency  of  other  mate- 
rials for  this  purpose  have  become  better  known.  Probably  the 
use  of  this  material  at  the  present  time  is  due  to  the  fact  that  it 
has  been  employed  for  so  many  years  that  engineers  are  prone 
to  follow  the  precedent  rather  than  look  into  the  merits  of  other 
protective  paints.  The  main  objection  to  red  lead  for  general  use 
as  a  metal  paint  lies  in  its  high  oxidizing  qualities,  which  soon 
burns  up  the  oil  and  attacks  the  iron  and  steel.  The  use  of  red 
lead  instead  of  preventing  corrosion  would,  under  these  circum- 
stances, produce  it.  Red  lead  is  made  under  conditions  which  per- 
mit great  quantities  of  oxygen  to  be  given  up  to  it  by  air,  and  as 
its  symbol  Pb3G4  would  indicate,  is  extremely  rich  in  oxygen. 

An  example  of  its  extremely  quick  oxidizing  properties,  and 
the  reason  for  its  being  a  poor  metal  paint,  is  shown  in  the  lad 
that  when  it  is  mixed  with  boiled  linseed  oil,  or  quick  drying  oil, 
by  adding  two  or  three  pounds  to  100  pounds  of  r;nv  linseed  oil 
and  heating  them,  it  is  utilized  to  make  what  is  known  as  rust 
joints  in  iron  pipe  work.  The  red  lead  is  smeared  on  the  scre^ 
threads  of  the  two  pieces  of  pipe  to  be  joined  together;  the  oxygon 
in  the  lead  attacks  and  rusts  the  iron  forming  a  permanent  joint 
that  in  most  cases  cannot  be  unscrewed.  This  in  itself  would  show 
how  impractical  it  is  for  use  as  a  protective  paint. 


352  iron 

There  arc  other  objections  to  it  if  used  in  a  pure  state — name- 
ly, thai  the  cost  of  the  material  and  the  cost  of  application  is  far  in 
advance  of  paints  which  are  better  adapted.  It  is  difficult  to  apply 
because  it  dries  so  rapidly  and  settles  hard  in  the  package;  it  is 
hard  to  brush  out  so  as  to  satisfactorily  cover  joints,  seams,  and 
boll  heads;  it  streaks  badly  on  account  of  its  coarseness  and  high 
specific  gravity;  the  pigments  separate  from  the  oil  and  leave  the 
coal  thick  in  one  place  and  thin  in  another.  The  matter  of  set- 
tling hard  and  the  fineness  of  the  pigmenl  can  be  somewhat  recti- 
fied by  proper  machine  mixing,  but  even  under  these  circumstances 
it  must  be  made  up  immediately  before  it  is  used,  so  as  to  prevent 
the  settling  out  and  hardening  of  the  pigment. 


CHAPTER  XX. 


ROOFING  AND  SHEET  METAL  WORK. 

ROOFING. 

There  are  several  methods  of  roofing  buildings,  dependent 
largely  upon  the  construction  of  the  building  itself.  Inasmuch  as 
smaller  hospitals  will  probably  be  built  of  ordinary  construction 
for  some  time  to  come,  all  methods  are  explained  for  each  kind  of 
building. 

Roofing  may  be  done  in  the  following  manner: 

First — The  so-called  composition  roof,  with  its  multitude  of 
methods. 

Second — Tin  or  metal  roofs,  which  are  also  of  several  kinds. 

Third — Waterproofing,  which  applies  to  flat  roofs  on  fireproof 
buildings. 

Besides  these  there  are  the  ordinary  shingle  roof  with  its 
variation  in  the  manner  in  which  the  shingles  are  laid;  the  slate 
roof;  and  the  tile  roof.  To  these  may  be  added  the  ready-made 
roofs,  or,  as  they  are  ordinarily  designated,  prepared  rooting,  of 
which  there  are  many  kinds.  The  last  named  are  used,  however, 
in  some  forms  under  the  third  class — namely,  waterproofing. 

The  composition  roof  consists  of  laying  tarred  felt  or  asphalt 
felt,  as  shown  in  Fig.  212,  and  is  used  only  on  flat  roofs.  The 
number  of  times  the  first  sheet  overlaps  the  last  sheet  is  desig- 
nated as  a  "ply,"  so  thai  we  may  have  three,  four,  five,  six,  etc., 
ply  roofs.  The  manner  of  laying  such  a  roof  is  as  follows:  Over 
a  wooden  deck  or  roof,  the  entire  roof  is  first  covered  with  a  dry 
felt  or  rosin  sized  sheathing  paper— namely,  <>nc  l hat  has  not  been 
tarred.  This  is  done  so  as  to  preveni  any  of  the  tar  or  asphalt 
from  coming  through,  owing  to  the  softening  under  the  heat  of  the 
sun,  and  from  staining  the  ceiling  of  the  top  floor,  and  also  to  pro- 
tect the  main  body  of  the  roofing  from  breaks  owing  to  shrinkage 
of  roof  boards.  Over  this  is  ordinarily  laid  a  five-ply  tar  pitch,  or 
asphalt,  felt,  or  slag  or  gravel  roof. 

Felt. — The  felt  should  not  weigh  loss  than  fifteen  pounds  to 
1  ho  hundred  square  feet,  known  as  a  "square,''  single  thickness. 

Pitch—  This  should  bo  of  the  host  quality  straight  run  coal 
tar,  distilled  direct  from  coal  tar.    There  should  be  no  less  than 


354 


ROOFING  A.ND  SHEET  METAL  WORK 


one  hundred  and  twenty  pounds  of  tins  for  each  square  of  one 
tnndred  square  feel   of  completed  roof.     The  nailing  should  be 

done  with  three-penny  barbed  wire  roofing  nails  driven  through  tin 

<  li  x '  s 

Gravel  —The  slag  or  gravel  should  be  of  such  a  grade  that  no 
particles  are  more  than  five-eighths  inch,  or  less  than  one-fourth 


FIG.  212. 


inch  in  size.  It  must  be  dry  and  perfectly  free  from  all  .last,  dirt 
or  other  foreign  matter.  When  this  gravel  is  put  on  in  cold 
weather  it  should  be  well  heated  just  before  it  is .applied,  and  there 
should  be  not  less  than  three  hundred  pounds  of  slag,  or  four  hun- 
dred pounds  of  gravel,  used  on  each  square  of  one  hundred  square 

feet  of  finished  roof. 

These  materials  should  be  applied  in  the  following  manner: 


ROOFING  ANI>  SIlKK'l    METAL  WORK 


355 


The  felt  shown  at  (A)  in  the  illustration  must  be  carefully  Laid 
with  a  lap  of  at  least  one  inch,  and  if  possible  three  inches  over  the 
preceding  sheet,  and  nailed  only  sufficiently  to  hold  in  place  until 
the  tarred  felt  is  laid.  It  is  preferable  to  use  no  nails  in  this. 
Over  this  dry  sheet  should  be  laid  two  thicknesses  of  the  tarred 
felt  (B),  lapping  each  sheet  seventeen  inches  over  the  preceding 
one,  and  mopping  back  with  pitch  the  full  width  of  each  lap,  as 
shown  in  Fig.  212.  Over  the  felt  thus  laid  there  is  spread  a  uniform 
coat  of  pitch  (C),  carefully  mopped  on.  On  this  coating  is  put 
three  full  thicknesses  of  the  felt  (D),  Lapping  each  sheet  twenty- 


FIG.  213. 
two  inches  over  the  preceding  one  and  nailing,  as  Laid,  every  three 
feet,  not  more  than  nine  inches  from  the  upper  edge.  This,  as 
shown,  would  make  a  three-ply  layer  over  the  preceding  two-ply 
layer.  As  in  the  case  of  the  latter,  the  full  twenty  inches  of  the 
three-ply  layer  must  be  mopped  hack  with  the  pitch.  The  entire 
roof  is  then  spread  over  with  a  uniform  coating  of  pitch  (  E),  into 
which,  while  hot,  in  cold  weather,  is  embedded  the  slag  or  gravel. 
If  a  "cap  sheet"  is  put  on,  this  must  be  laid  over  the  roof  while  the 
even  coating  is  wet,  lapping  a1  least  three  inches,  and  then  mopped 
evenly  with  a  coating  of  the  pitch  and  the  gravel  or  slag  imbedded 
in  this  while  hot. 

The  roof  felt  must  he  broughl  well  upon  the  walls  and  all 
other  projections  and  thoroughly  mopped  and  fastened.  The  walls 
can  be  flashed  and  counter-flashed  with  galvanized   iron,  tin  or 


356 


ROOFJXc;  AND  SHEET  METAL  W0KK 


copper,  as  shown  in  Figs.  213,  214.  These  flashings  are  cemented 
into  the  brick  or  stone  courses,  as  shown,  with  slaters'  cement.  A 
roof  such  as  described  could  also  be  put  over  a  cement  or  tile  roof 
on  fireproof  buildings,  if  these  are  flat  with  the  ordinary  fall  of 
from  one-half  to  one  inch  to  a  foot  toward  the  gutter.  The  roof 
could  not,  however,  be  used  on  a  slanting  or  hip  roof,  owing  to  the 
pliability  of  the  material  and  its  tendency  to  run  under  the  heat  of 
the  sun. 

Tin  Roof. — Tin  is  used  on  either  the  flat  or  sloping     rod's. 
Knot's  with  less  than  one-third  pitch  are  made  with  flat  seams.    Tin 


no.  214. 

comes  in  sheets  from  14x20  inches  dimension  to  20x28  inches.  The 
smaller  size,  L4x20  inches,  shonld  be  used  on  all  flat  root's,  because 
the  larger  number  of  seams  stiffen  the  surface  and  help  to  pre- 
vent buckles  and  rattling  in  stormy  weather.  For  flat  seam  red' 
one  inch  barbed  and  tinned  roofing  nails  should  be  used,  not  over 
six  inches  apart,  well  under  the  edge.  They  should  be  well  cov- 
ered up  and  the  seams  should  be  pounded  down  over  the 
edge  with  a  wooden  mallet.  Nails  must  never  be  exposed.  The 
seams  should  be  made  with  great  care;  and  sufficient  time  must 
be  taken  to  properly  "sweat"  the  solder  into  the  seams. 

Steep  tin  roofs  should  be  made  with  standing  seams  and  from 
sheets  20x28  inches.  The  sheets  are  first  double  seamed  and  sol- 
dered together  into  long  strips  that  reach  from  eaves  to  ridge.    The 


ROOFING  AND  SHEET  METAL  WORK  351 

sloping  seams  are  composed  of  two  "upstands,"  interlocked  and 
held  in  place  by  cleats.  The  standing  seams  are  not  soldered,  but 
are  simply  locked  together  with  the  cleats  folded  in  from  15  to  IS 
inches  apart.    Nails  should  be  driven  into  the  cleats  only. 

While  it  is  always  cheapest  to  use  the  best  material,  roofing 
plates  with  a  lesser  coating  may  be  used  for  steep  standing  seam 
roofs.  Roofing  plates  in  which  the  iron  body  weighs  50  pounds 
per  100  square  feet  are  more  suitable  than  plates  621/2  pounds  per 
100  square  feet,  because  the  seams  in  the  lighter  plates  will  not 
suffer  as  much  from  contraction  and  expansion  as  the  thicker 
plates.  The  amount  of  terne  coating  on  the  lighter  sheets  should 
in  all  cases  be  fully  as  heavy  as  on  the  heavier  plates. 

In  late  years  the  anxiety  of  some  manufacturers  to  satisfy  the 
demand  of  the  people  for  cheap  goods  has  resulted  in  the  intro- 
duction of  many  inferior  grades  of  roofing. 

This  latter  class  of  material  may  suit  for  some  purposes  out- 
side of  roofing,  or  for  roofs  on  temporary  buildings,  but  for  roofs 
that  are  expected  to  last,  the  "double  dipped"  and  "extra  coated" 
plates  should  be  adopted. 

The  use  of  acid  in  soldering  seams  in  a  tin  roof  is  to  be  care- 
fully avoided;  acid  coming  in  contact  with  the  bare  iron  on  the 
cut  edges  and  corners  where  the  sheets  are  folded  and  Seamed 
together  will  cause  rusting.  No  other  soldering  flux  but  good  rosin 
should  be  used  and  all  acid  spots  and  deleterious  substances 
should  be  removed  as  the  tinner's  work  is  being  finished.  Lumps 
of  rosin  left  on  the  roof  will  melt  in  the  sun,  stick  to  the  roof, 
cause  blisters  and  prevent  paint  from  adhering. 

For  valleys,  spouts  and  gutters  of  a  tin  roof,  no  other  metal 
than  terne  plates  should  be  employed,  because  the  galvanic  action 
produced  by  different  metals  coming  in  contact  with  each  other 
will  cause  disintegration  under  atmospheric  influences. 

The  sheeting  boards  underlying  the  roofing  tin  should  he  pul 
close  together. 

The  wood  should  be  well  seasoned,  dvw  and  all  knots  should 
be  culled  out.'  It  is  also  advisable  to  cover  the  hoards  with  good 
building  paper  before  the  tin  is  laid  on.  ('are  should  also  In- 
used  in  the  quality  of  paper  placed  under  the  tin.  Where  paper  is 
used  it  should  not  be  anything  that  will  technically  answer  for 
paper,  but  a  good  waterproof  one  that  will  ao1  absorb  tin  damp- 
ness, dry  at  once,  and  protect  the  tin  from  gases  and  dampness 
underneath.  The  paper  serves  to  exclude  from  the  tin  injurious 
vapors,  gases  or  fumes  that  continually  rise  from  the  rooms  below. 
When  no  paper  is  used,  the  tin  must  in  all  cavs  bo  painted  on 
the  under  side  with  good  reliable  paint   before  it   is  laid  and   fas- 


358 


l.ooEIXO  ANH  SHEET  METAL   WORK 


tened  on  the  roof.  The  outside  should  receive  the  paint  as  soon 
as  the  roof  is  finished  (see  Painting  under  Chapter  on  Iron).  To 
make  tin  roofs  last  the}'  should  be  repainted  every  two  or  three 
years  with  good  paint.  The  frequency  of  the  intervals  will  de- 
pend largely  on  the  climatic  conditions  of  the  country. 

TILE,  SLATE  AND  SHINGLE  ROOFS. 

Ornamental  Tile.- — Slate  and  shingles  are  used  only  on  slop- 
ing roofs — that  is,  those  with  gables  or  when  the  roof  slopes  on 
all  sides  to  a  point  or  a  ridge — on  dormers  and  turrets  and  on 
ornamental  portions  of  the  building  above  the  roof.  The  slope  of 
such  roofs  should  never  be  less  than  30  degrees  from  the  hori- 
zontal and  should  have  more  angle  for  the  tile  than  for  the  slate. 
The  method  of  putting  on  these  roofs  follows  practically  the  same 
lines.  The  shingle  roofs  need  no  special  mention,  except  that  they 
are  not  advocated  for  hospitals.    Tin  or  slate  roofs  are  preferable 


fig.  215. 

as  they  arc  fireproof,  and  even  if  the  hospital  is  of  ordinary  con- 
st  ruction  instead  of  fireproof,  it  will  somewhat  protect  the  build- 
ing from  flying  sparks  should  a  tire  occur  in  the  vicinity.  More- 
over, shingles  are  not  economical,  as  the  best  shingle  roof,  well 
creosoted  to  preserve  the  shingles,  will  not  last  for  more  than  ten 
years,  and  in  mosl  climates  rarely  that  length  of  time.  A  slate 
roof  will  last  as  long  as  the  building  stands,  and  with  proper  care 
a  g I  tin  roof  will  last  as  long  as  a  slate  roof. 

Tile  root's  and  slate  roofs  are  used  only  on  sloping  surfaces, 
as  all  of  the  space  in  hospitals  is  of  value,  and  ornamental  roofs 
with  attics  nndei  them  are  not  recommended.  A.s  mentioned  here- 
in, the  added  expense  of  such  roofs  could  be  better  applied  else- 
where  in  the  hospital.  If  such  roofs  are  used  the  following  will 
he  of  assistance : 

Slate  should  lie  of  the  unfading  variety  and  put  on  in  plates 
of  about  eight  inches  by  sixteen  inches,  with  all  proper  flashings 


ROOFING  AND  SHEET  METAL  WORK  359 

and  counter-flashings,  as  described  herein.  All  slate  should  be 
punched  to  receive  the  nails,  and  each  slate  fastened  by  at  leasl 
two  copper  or  copper-coated  nails.  Slate  should  be  Laid  with  a 
lap  of  three  inches  of  the  third  slate  over  the  first  row,  as  shown 
in  Fig.  215.  All  hips  and  ridges  on  the  roof  should  have  the  slate 
doubled  and  laid  in  slater's  cement.  Under  all  slate  there  should 
be  two  thicknesses  of  dry  waterproof  sheathing  fell  or  paper. 

Tile  roofs  are  laid  according  to  the  tile  used.  If  shingle  tile 
are  used,  they  are  laid  just  as  slate  is,  except  that  at  the  ridges 
either  a  flat  or  ornamental  ridge  mold  is  put  on.  The  ornamental 
types  of  tile  are  all  made  so  that  they  fit  and  overlap  in  specially 
prepared  grooves  and  slots,  with  corresponding  raised  portions 
and  drips  to  fit  into  these.  This  is  done  both  on  top  and  bottom 
and  on  edges.  The  ridges  and  hips  of  the  roofs  are  all  put  on  in 
ornamental  tile  with  finials,  etc.,  as  required  by  the  design  of  the 
building  with  such  roofs. 

Prepared  Roofing. — There  are  many  varieties  on  the  market 
and  they  need  no  special  mention  here.  They  are  prepared  of  rub- 
ber compounds,  tar,  asphalt  and  other  materials,  each  having  its 
own  merits.  These  roofing  materials  come  in  large  rolls  and  are 
laid  on  the  roof  with  a  slight  overlap  at  the  joining  made  for  this 
purpose  and  are  cemented  at  these  joints.  Nails  with  tin  washers 
are  driven  into  these  overlaps  and  cemented  over. 

WATERPROOFING. 

Waterproofing  as  applied  to  roofs  may  be  done  in  several 
ways.  The  tile  or  concrete,  as  the  ease  may  be,  should  be  per- 
fectly smooth  and  graded  to  carry  the  water  to  the  outlet  or  gut- 
ters. Over  such  a  roof  should  be  laid  a  five-ply  cold  tar  pitch,  felt 
and  slag,  or  gravel  roof,  which  should  be  Constructed  as  follows: 

Felt. — The  felt  should  not  weigh  less  than  15  pounds  per  l'11' 
square  feet,  single  thickness. 

Pitch. — The  pitch  should  be  the  best  quality  of  straight  run 
cold  tar  pitch,  distilled  direct  from  the  American  coal  tar,  and 
there  should  not  be  less  than  200  pounds  of  this  used  for  each 
100  square  feet  or  one  square  of  completed  roof. 

Gravel. — The  slag  or  grave]  should  be  the  same  as  for  roofs 
over  sheathing  hoards  as  described  herein,  and  there  should  not 
be  less  than  300  pounds  of  slag,  or  4()i)  pounds  of  gravel,  use!  on 
each  100  square  feet  or  one  square  of  the  roof. 

These  materials  should  be  applied  as  fellows:  The  concrete 
or  tile  should  be  coated  with  hoi  pitch  (B),  which  should  be 
mopped  on  uniformly.  Over  this  coating  of  pitch  there  should 
be  laid  two  thicknesses  of  the  tarred  fell  (<'),  lapping  each  sheel 


360 


ROOFING  AND  SHEET  METAL  WORK 


seventeen  inches  over  the  preceding  one  and  mopping  back  with 
pitch  (D),  the  full  width  of  each  lap.  On  the  felt  thus  laid  there 
should  be  spread  a  uniform  coating  of  pitch  (?]).  thoroughly 
mopped  on.  ( )ver  this  then  should  be  laid  three  full  thicknesses  of 
the  felt  (F),  lapping  each  sheet  twenty-two  inches  over  the  pre- 
ceding one.     When  the  felt  is  thus  laid  it  should  be  mopped  back 


fig.  21(5. 

with  pitch  (<i),  the  full  width  of  the  twenty-two  inches  under 
each  lap.  Over  this  entire  surface  a  uniform  coating  of  pitch 
should  he  put  on,  into  which,  while  hot,  should  be  embedded  the 
slag  or  gravel  (II).  A  cap  sheet  can  he  put  over  the  entire  roof 
as  shown,  but  this  is  not  necessary. 

Such  roofs  can  also  be  applied  in  six-ply  and  cap  sheet,  and 


ROOFING  AND  SHEET  METAL  WORK 


361 


seven-ply  and  cap  sheet,  but  their  wearing-  quality  is  no  better  than 
the  five-ply  and  cap  sheet  roofs,  if  put  on  properly  and  carefully. 
Roofs  can  also  be  waterproofed  in  the  same  manner  as  are 
walks  or  basement  floors.  In  this  method  the  waterproofing  is 
placed  over  the  tile  or  concrete  and  a  finished  roof  of  cement  or 
tile  put  over  this.  When  done  in  this  maimer  the  waterproofing 
must  be  applied  with  extreme  care,  and  when  so  done  makes  prac- 


riii.   'in. 

tically  an  indestructible  ro«»r.    Such  a  roof  can  be  used  for  a  mul 
titude  of  purposes.     Walking  on  it  docs  not   injure  it,  inasmuch 
as  it  is  practically  a  cemenl  floor.    The  cemenl  top  dressing  should 
be  treated  with  one  of  the  compounds   used   for   making  cemenl 
waterproof.    The  waterproofing  can  he  done  as  follows: 

The  felt  and  pitch  are  the  same  as  for  the  roof  just  described; 


362 


ROOFING  AX!)  SHEET  METAL  WOBK 


the  materials  to  be  used  as  follows:  The  concrete  or  tile  at  A  is 
coated  with  ho1  pitch  I  B),  and  the  same  roof  put  on  as  described 
above  for  roof  over  concrete.  After  the  top  surface  is  uniformly 
mopped  with  the  hot  pitch  the  entire  roof  is  finished  with  either 
a  cenienl  top  dressing  aboul  V/2  to  2  inches  thick,  or  is  laid  with 
a  course  of  vitrified  plate  tiles  (I).  6x9x1,  laid  in  and  thoroughly 
grouted  with  Portland  cement  mortar  (J).  The  same  general 
specificntiou  applies  where  brick  or  composition  tile  are  used  in- 
stead of  the  vitrified  plate  tile.     In  putting  a  roof  on  of  this  char- 


1  |    ^ 


FIG.  218. 

acter,  it  is  accessary  to  flash  and  counter-Hash  with  tin,  galvanized 
iron,  or  copper,  as  shown  in  Fig.  214. 

Sheet  Metal  Work.  -Under  the  heading  of  sheet  metal 
comes  the  construction  of  all  such  parts  of  the  building  as  are 
made  of  galvanized  iron,  copper  and  tin,  except  roofs  and  ven- 
tilating Hue-. 

Galvanized  Ikon.  The  galvanized  iron  work  include-  the  sky- 
lights and  vent-:  covering  of  outside  work  when  constructed  of 
wood;  cornices  not  made  of  copper  or  other  materials,  down 
spouts  or  rain  leaders,  and  all  gutters,  where  these  are  not  made 


ROOFING  AND  SHEET  METAL  WORK 


363 


of  tin  or  copper.     Flashings  are  also  made  of  this  material,  but 
can  be  made  of  copper  or  tin. 

Cornice.— Cornices    are    made    ordinarily  of  twenty-two  to 
twenty-six  gauge  iron  with  joints  riveted  every  two  inches  and 
then  soldered  tightly.    The  cornice  is  fastened  to  the  building  with 
stays,  as  shown  in  Fig.  218.  These  stays  should  be  made  of  14x1 '  ■_.- 
inch  iron,  securely  riveted  to  the  galvanized  iron  every  two  feet, 
and  these  stays  anchored  into  the  wall,  as  shown  at  A.     If  a 
frieze  is  put  on  the  cornice  of  galvanized  iron  shown  at  A  in  the 
illustration,  it  should  be  of  crimped  iron,  as  the  large  straighl 
surface  is  liable  to  buckle  and  get  out  of  shape,  while  the  crimps 
reinforce  and  stiffen  the  whole  surface.    Blocks  should  be  built  in 
the  wall  to  receive  this  frieze,  so  that  it  can  be  securely  fastened 
in  its  entire  length.     These  are  shown  in  the  illustration  at  B. 
The  deck  or  top  of  the  cornice  must  be  put  upon  a  boarded  deck 
or  platform,  as  shown  at  C.     This  platform  is  built  on  lookouts, 
which  are  placed  about  two  feet  apart  and  are  shown  at  E.    These 
lookouts  or  brackets  are  also  built  into  the  walls  which  run  behind 
the  cornice,  and  are  usually  shaped  to  admit  the  crown  or  top 


fig.  219. 

members  of  the  cornice.  Brackets  on  cornices  are  usually  stamped 
and  are  soldered  on  if  the  design  of  the  cornice  is  made  with  such 
ornamental  features. 

Gutters.— Gutters  arc  sometimes  run  in  the  main  cornice  of 
the  building,  but  more  often  independently  of  this!  This  depends, 
however,  upon  the  design  of  such  roofs.  11'  the  roof  ,s  sloping. 
the  gutter  preferably  would  be  in  the  cornice,  although  on  Hat 
roofs  they  are  rarely  placed  there.  Gutters  are  made  of  22-gauge 
galvanized  iron  and  are  fastened  with  hooks  ami  stays,  as  shown 
in  Fig.  219,  in  which  A  shows  the  hook  and  B  the  stay.  The  iron 
is  well  Hashed  under  the  roof  as  shown.  The  gutter  slopes  not  less 
than  one-half  inch  to  the  foot  to  the  downspout,  with  a  strainer 
at  the  lower  end  to  prevent  foreign  matter  from  clogging  up  the 
spouts.  Gutters  ofien  take  the  form  of  a  leader  head,  which  is 
shaped  somewhat  like  a  large  deep  pan.     If  Midi  heads  are  used, 


364 


ROOFING  AND  SHEET  METAL  WORK 


their  sides  must  he  carefully  calculated  so  that  they  will  be  suffi- 
ciently large  to  contain  the  water  which  runs  into  them.  They 
are  usually  placed  where  a  continuous  gutter  cannot  be  used,  and 
the  entire  water  of  a  Large  roof  discharges  into  one  or  two  of 
them,  consequently  they  act  somewhat  as  an  overflow  reservoir. 
Gutters  can  he  made  ornamental  and  overflow  heads  can  be  made 
in  a  multitude  of  designs. 

Downspouts.  A  sufficient. number  of  these  must  be  supplied 
to  carry  off  the  water  easily.  They  should  never  be  less  than  six 
indies  in  diameter,  unless  there  are  great  numbers  of  them;  they 
can  be  of  square  or  rectangular  pattern,  but  of  whatever  shape 
they  should  always  be  made  in  the  expansion  pattern,  as  shown 


fig.  220. 

in  Figs.  220,  221.  They  are  made  in  this  form  to  permit  of  expan- 
sion in  case  of  freezing.  Downspouts  can  also  be  made  ornamental 
with  ornamental  heads  and  stays.  All  downspouts  run  continuously 
from  the  gutter  to  the  sewer  stub.  It  is  well  to  have  the  tower 
three  i"  five  feel  of  cast  iron,  to  prevent  their  destruction  by  heavy 
objects  coming  forcibly  in  contacl  with  them.  The  iron  foot  piece- 
can  he  ornamentally  cast,  or  can  be  heavy  cast  iron  soil  pipe,  de- 
pending upon  their  Location.  All  downspouts  should  be  securely 
fastened  to  the  wails,  al  least  every  four  \\  el  in  their  entire  length, 
with  galvanized  iron  hooks,  as  shown  in  illustration.  These  are 
made  plain  or  ornamental  as  occasion  requires,     i downspouts  are 


ROOFING  AND  SHEET   METAL   WORK 


365 


made  of  cast  or  wrought  iron  pipe  in  some  cases,  but  in  such  in- 
stances they  are  usually  run  inside  the  building. 

Flashings. — Flashings  are  put  on  the  roof,  as  shown  in  Fig. 
213,  214,  and  are  ordinarily  run  up  on  the  wall  at  least  eight  inelu's 
and  cemented  into  the  course  between  the  brick,  or  in  slots  cut  for 
the  purpose  in  stone.  Counter-flashings  are  sometimes  put  on,  as 
shown,  the  metal  being  put  over  the  flashing  in  the  same  man- 
ner as  the  flashing  is  fastened  and  cemented  into  the  wall.  These 
counter-flashings  are  brought  down  to  the  roof  level  and  bent  out 


fig.  221. 

with  a  drip.  Flashings  are  also  used  under  shingle,  tile  or  slate 
roofs  in  the  valleys.  These  flashings  should  extend  under  the  tile 
on  either  side  at  least  eight  inches.  On  sloping  roofs,  cornices, 
when  of  metal,  and  gutters  are  flashed  under  the  roofs,  as  are  also 
the  gutters  on  flat  roofs. 

Vents. — Vents  on  skylights  and  those  over  the  sterilizing 
apparatus  can  be  of  several  patterns.  Figs.  222,  22.".  show  two 
forms  of  vents.  Those  over  the  sterilizing  rooms  should  bo  of  Large 
diameter,  start  at  the  ceiling  lino  and  inn  continuously  at  least 
two  feet  above  the  roof.  There  should  be  two  vents  on  each  sky- 
light, their  size  depending  upon  the  size  of  the  room  underneath. 
These  vents,  however,  should  not  be  employed  when  those  as  (h> 
scribed  in  Ventilating  are  used.  Wnere  necessary  such  vents 
should  have  a  valve  and  a  cord  to  operate  them. 


m 


ROOFING  ANI»  SHEET   METAL   WORK 


Skylights. — Skylights  should  be  so  constructed  thai  they  will 
exclude  all  condensation.  In  hospitals  all  skylights  should  face 
north  only — the  sides  and  top  being  built  of  tile,  concrete  or  wood, 
as  the  case  may  be.  In  the  last  named  form  the  sides  and  top  arc 
covered  with  galvanized  iron,  or  the  top  is  roofed  as  described 
under  Hoofing.  The  skylight  should  be  made  double  in  all  of  its 
parts,  as  shown  in  Figs,  (54  and  98.  Such  skylights  will  exclude  all 
condensation.  As  shown  in  these  figures,  the  outer  glass  is  remov- 
able to  permit  of  cleaning  both  sets  of  glass.    This  can  be  done  by 


fig.  222. 

setting  the  wire  glass  in  angle  iron  doors,  the  inside  lights  being 
clear  plate. 

This  method  of  putting  in  double  glass  is  superior  to  that  of 
the  single  skylight  glass,  and  the  so-called  ceiling  lights.  In  the 
latter  form  of  skylight  there  are  two  methods  of  nutting  in  such 
ceiling  lights— first,  supporting  them  in  a  loose  iron  frame,  or  a 
hinged-iron  frame,  so  that  the  whole  light  can  he  Lowered  for 
-leaning.  This  has  the  decided  disadvantage  of  not  being  dust- 
proof,  and  being  extremely  heavy  to  handle  for  the  I  iv.jiient  clean- 
ings which  would  be  necessary  in  a  light  which  lies  horizontal. 
The  second  method  is  that  of  putting  a  dust-proof,  air-tight  light 
at  the  ceiling;  in  other  words,  of  permanently  cementing  such  a 
light  into  place.  If  this  is  done  it  is  necessarj'  to  have  attic  space 
above  this  sufficient  to  permit  of  one  or  more  doors  being  put  into 


HOOFING  AND  SHEET  METAL  WORK 


36 


U 


the  walls  of  the  skylight  duet.  Inasmuch  as  it  is  impossible  to  get 
the  outer  lights  of  a  skylight  absolutely  air-tight,  this  ceiling  light 
is  subject  to  fine  particles  falling  upon  it.  and  so  obscuring  the  light 
and  making  it  necessary  to  clean  it.  It  is  difficult  to  do  this  if  the 
light  or  lights  are  of  any  extent,  as  it  is  impossible  to  get  over 
them  without  special  apparatus  for  the  purpose.    The  frame  ean- 


fig.  223. 

not  be  made  of  any  larger  size  than  will  just  bear  the  weight  of 
the  glass,  owing  to  the  fact  that  the  light  from  above  causes  a 
shadow  to  be  cast  by  these  horizontal  bars. 

Copper. — Wherever  galvanized  iron  or  other  forms  of  sheet 
metal  can  be  used  it  is  also  possible  to  use  copper.  Cornices, 
downspouts  and  flashings  and  even  entire  roofs  can  be  made  of 
this  material.    The  main  objection  to  it  in  great  quantities  is  its 


fig.  224. 

increased  cost  over  other  forms  of  sheet  metal  work,  owing  to  the 
added  cost  of  material,  and  because  i\  is  somewhat  softer  than 
the  other  metals  so  used. 

Eoods.— All  the  hoods  iW  sterilizers  and  Tor  other  apparatus 
where  fumes  and  steam  are  to  be  conveyed  Prom  the  room  through 
the  ventilators  which  have  been  mentioned  herein  are  ordinarily 


368 


ROOFING  AND  SHEET  JIL'IAL  WORK 


made  of  copper.  This  copper  is  planished  or  polished.  Such 
hoods  are  usually  made  by  the  manufacturers  of  sterilizing  ap- 
paratus, but  as  the  requirements  in  no  two  cases  are  exactly  alike, 
all  hoods  are  ordinarily  made  to  fit  the  particular  place- for  which 
they  arc  intended.     These  hoods  should  he  thoroughly  reinforced 


fig.  225. 

and  can  be  hung  either  free  from  the  ceiling,  or  they  can  be  set  to 
the  wall  and  suspended.  Figs.  224,  225  show  the  two  methods  of 
these.  These  hoods  should  all  have  condensation  gutters  which 
lead  to  a  small  tube  or  spout  properly  connected  or  drained  into  a 
sink. 


CHAPTER  XXI. 

FLOORS  AND    WAINSCOTS 

This  subject  is  one  which  has  been  discussed  at  greater  length 
and  with  more  diversity  of  opinion  than  probably  any  one  portion 
in  the  construction  of  hospitals.  There  seems  to  be  no  general 
agreement  of  opinion  on  the  subject,  nor  are  there  any  standards 
which  can  be  made.  Precedent  bears  no  relation  to  the  subject, 
apparently,  for  what  is  considered  ideal  by  one  authority  will  be 
disparaged  by  another,  until  there  is  divergence  that  is  both  con- 
fusing and  unfortunate.  Observation  and  test  by  actual  experi- 
ence does  not  seem  to  be  conclusive  evidence  of  the  superiority 
of  one  material  over  another.  Glass  for  wainscots  was  thought 
to  have  solved  the  much-mooted  question  for  operating  rooms. 
but  no  sooner  was  the  decision  given  that  this  must  be  the  besl 
material  for  the  purpose  than  some  one  brought  conclusive  proof 
that  tile  is  superior.  As  an  example  of  this,  in  the  discussion  of 
the  best  material  for  floors  for  operating  rooms,  Dr.  Kurd  says: 

k'I  think  I  can  say  that  on  the  whole  there  are  no  good  floors 
for  operating  rooms,  wards  and  kitchens.  I  mean  by  that,  no 
perfect  floors.  Of  course,  some  floors  are  better  than  others,  but 
all  of  them  need  careful  management.  I  think  it  was  Webster 
who  said,  'If  I  write  upon  copper  it  will  corrode;  if  upon  marble, 
it  will  perish  away.'  And  I  think  the  same  could  be  said  of  any 
article  for  a  ward  floor.  We  think  the  best  floor,  it'  you  can  gel 
the  best  material  and  get  it  carefully  laid,  is  a  maple  floor.  It  is 
a  floor,  however,  that  needs  great  care,  and  it  is  a  very  uncertain 
floor  for  old  gentlemen.  Next  in  point  of  durability  conic-  the 
rift-sawed  Southern  pine.  If  that  is  properly  taken  care  of.  ami 
not  rubbed  to  death,  I  think  you  will  And  it  a  very  pleasing  floor, 
not  as  slippery  as  the  other,  and  in  many  respects  is  best. 

"Within  the  past  few  years,  however,  I  have  com'  to  have 
different  ideas  about  ward  floors.  Some  six  years  ago,  when  our 
ward  floors  began  to  give  way,  and  the  question  came  up  as  to 
whether  we  should  renew  the  floor  or  in  some  way  proteel  it.  I 
decided  to  place  linoleum  of  a  color  very  much  like  hard  pine  on 
this  ward,  floor.  T  also  found  that  by  going  to  the  manufacturers 
that  T  could  get  it  of  any  width.  I  therefore  had  it  made  twelve 
feet  wide.    I  also  had  considerable  dilhcultv  in  finding  a  substance 


370  FLOORS  A  X I )  W  A I N  S<  ( 'IS 

thai  would  have  a  pleasing  appearance  to  l>e  used  to  fasten  the 
edges  down;  and  finally  brass  strips  were  used,  covering  the 
edge-  of  the  material  and  fastening  it  securely.  This  linoleum  was 
laid  down  some  years  ago,  and  has  been  treated  the  same  as  a 
hardwood  floor,  oiled  and  rubbed  with  wax  and  kept  good  with 
turpentine.  That  linoleum  is  as  good  as  the  day  it  was  laid  down, 
and  i1  Looks  as  well.  I  think  so  well  of  it  that  if  1  ever  should 
build  a  new  hospital  ward,  L  would  have  comparatively  cheap  floor- 
ing pu1  down  and  cover  it  with  Linoleum.  It  makes  a.  very  satis- 
factory floor.  It  is  cemented  down.  I  have  had  some  experience 
w'nh  rubber  tiling,  and  I  do  not  like  it.  I  have  had  some  experi- 
ence with  cork  tiling,  and  it  makes  a  very  satisfactory  floor.  The 
only  objection  i>  that  it  costs  more  and  will  not  Lay  as  level. 

"For  the  operating  room.  L  do  not  know  of  anything  better 
than  hexagonal  tiling.  It  should  be  laid  with  the  greatest  care. 
The  great  difficulty  is  that  sometimes  the  bedding  is  uneven." 

"Linoleum  might  to  be  put  face  down  in  summer  along  the 
corridor  and  tramped  over  two  or  three  weeks  to  get  the  stretch 
mil  of  i!.  1  do  not  know  just  what  happens  to  it,  but  we  get  it 
more  uniform.  When  it  is  first  laid  down  I  have  sometimes  known 
of  the  difficulties  of  which  Mr.  Test  speaks;  it  is  due  to  the  fact 
that  there  is  air  under  it  when  it  is  laid  down.  Frequently  if  it  is 
raised  ^n  one  side  and  the  air  let  out  you  do  not  have  this  trouble. 
Yon  do  not  have  this  trouble  anyway  if  it  is  carefully  laid  down 
and  the  stretch  taken  out  of  it." 

There  seems,  therefore,  to  be  some  opinion  that  linoieum 
i>  adaptable  to  wards,  but  from  experience  the  authors  nave  found 
that  the  ordinary  maple  floor,  properly  laid  and  taken  care  of,  is 
as  satisfactory  as  any  other  floor  for  this  purpose.  The  subject, 
however,  is  one  which  apparently  is  rather  a  matter  of  opinion 
than  of  a  scientific  and  careful  research  and  observation.  Cli- 
matic conditions,  the  class  of  patients,  the  wear  and  taar  owing  to 
usage,  and  the  general  conduct  of  the  institution  are  all  elements 
to  be  taken  into  consideration.  The  subject  is  treated  therefore 
from  the  point  of  adaptability,  economy  and  construction,  and  is 
pel  forth  lor  each  space  for  each  material. 

Floor  classifications  are: 


1. 

Wood. 

•) 

Linoleums 

::. 

Cork. 

4. 

Terrazzo. 

5. 

Tile. 

6. 

Glass. 

7. 

Marble. 

FLOORS   AND    WAINSCOTS 


371 


The  spaces  in  which  they  are  placed  are:  Kooms,  wards. 
corridors,  administration  and  operating  department,  toilet  rooms 
and  kitchen  departments. 

Wainscot  classifications  are: 
Cement. 

Slate  or  soapstone. 
Tile. 
Marble. 
Glass. 

The  spaces  in  which  they  are  placed  are:  Corridors,  operat- 
ing department,  kitchen  department  and  toilet  rooms. 

Marble  for  ornamental  purposes  will  not  be  dwell  upon,  as 
there  is  no  limit  to  such  a  classification,  it  being  a  subject  wholly 
on  the  esthetic  side,  and  not  on  the  practical  or  necessary. 

"Wood  Floors. — The  laying  of  such  floors  and  their  treatment 
has  been  fully  explained  elsewhere.  In  hospitals  they  are  adapta- 
.  ble  in  all  spaces  where  strict  economy  is  necessary,  except  operat- 
ing rooms.  While  this  feature  of  economy  may  be  expedient,  it  is 
not  practical  in  the  end,  as  the  constant  care  which  is  necessary 
in  much  traveled  spaces,  such  as  corridors,  would  more  than  offset 
the  cost  of  some  other  form  which  would  be  less  liable  to  wear  and 
tear. 

Maple  floors  are  the  best  of  wood  floors,  as  the  wood  is  close- 
grained,  and  if  properly  seasoned  and  finished  it  is  admirable. 
In  laying  these  floors  they  must  be  closely  and  carefully  driven 
and  securely  nailed. 

Linoleum. — What  Dr.  Hurd  has  said  in  reference  to  this  ma- 
terial fully  covers  its  qualities.  It  might  be  added  that  it  is  not 
the  ideal  floor  for  corridors.  The  inlaid  linoleums  are  the  best 
under  all  circumstances,  although  their  first  cost  is  considerably 
more  than  that  of  the  ordinary  print  varieties.  The  latter  are 
not  to  be  compared  in  wearing  quality,  as  they  will  not  lasl  more 
than  a  year  or  two  at  most,  while  the  inlaid  kind  will  lasl  Tor  many 
years.  Inlaid  linoleums  are  of  two  kinds — the  ordinary  linoleum, 
which  is  about  Vs  mcn  thick,  and  the  cork  linoleum,  abtiiil  (  j  inch 
thick.  The  former  comes  in  widths  of  two  yards  and  in  lengths 
up  to  thirty  yards.  With  these  it  would  be  necessary  to  have  hut 
two  joinings  in  wards  up  to  eighteen  feet  in  width,  as  the  linoleum 
would  be  run  the  length  of  the  room,  lirass  strips  are  not  recom- 
mended for  the  covering  of  the  joints,  as  they  protrucre,  however 
flat  they  may  be,  and  furthermore  the  linoleum  can  he  laid  by 
tacking  along  the  edges.  The  security  of  the  joints  can  he  mate- 
rially enhanced  by  cementing  the  joining  edges,  covering  a  space 
of  about  two  inches  in  width  and  running  the  entire  length  of 
such  joints. 


372  FLOORS  AND   WAINSCOTS 

Buckling-  of  linoleum  is  due  to  several  causes,  all  of  whien 
can  be  avoided  without  Laying  the  materia]  face  down  for  a  con- 
siderable period,  as  suggested.  This  is  neither  convenient  nor 
expedient.  The  material  must  be  carefully  laid  by  experienced 
men,  and  the  rooms  should  be  neither  hot  nor  cold  when  this  is 
done.  The  main  precaution  to  he  noted,  however,  is  the  condition 
of  the  floor  over  which  the  linoleum  is  to  be  placed.  Such  floors 
must  be  absolutely  dry.  Mopping  them  before  the  material  is 
put  down  is  never  to  be  done,  and  if  they  are  scrubbed  this  should 
be  done  far  enough  in  advance  to  permit  them  to  dry  out  thor- 
oughly. 

Cork  linoleum  is  admirable  in  many  ways.  It  is  noiseless, 
warm  and  sanitary.  It  should  be  laid  like  the  ordinary  inlaid 
linoleum,  the  same  precautions  being  necessary  in  the  laying'  as 
are  observed  for  the  latter.  Cork  linoleums  can  also  be  cemented 
over  the  entire  area.  This,  however,  is  not  necessary.  There  are 
cork  tiles  which  are  laid  in  this  manner,  and  which  are  finished 
and  treated  like  wood  Moors.  They  are  not  subject  to  much 
expansion  and  contraction  and  have  many  superior  qualities.  In 
laying  these,  however,  it  is  not  necessary  to  have  a  wood  floor 
under  them,  as  the  cement  into  which  they  are  set  can  be  put  over 
tile  or  rough  concrete.  The  cement  is  put  into  all  joints  as  a 
grouting,  and  the  floor  has  a  continuous  appearance.  The  objec- 
tion to  such  floors  is  their  comparative  shortness  of  life.  They 
must  be  refinished  frequently.  They  are  made  of  small  particles 
under  extremely  high  pressure.  They  can  be  used  in  rooms  and 
wards,  but  are  not  a  good  material  for  corridors. 

TERRAZZO,  FLAKE  MOSAIC  AND  COMPOSITION  FLOORS. 

Terrazzo.— Terrazzo  in  its  original  form  had  extremely   dry 

lime  mortar  for  its  principal  ingredient.  Into  (his  were  placed 
pieces  of  marble,  the  whole  beaten  hard,  and  rubbed  down  and 
polished.  ]n  laying  floors  of  this  character,  it  is  accessary  to  have 
a  heavy  concrete  base  not  less  than  three  inches  thick.  The  con 
Crete  for  this  work,  as  also  for  tile  floors  and  glass  floors,  should 
be  made  of  Portland  cement,  torpedo  sand  and  broken  stone  in 
proportions  of  one  of  cement  to  two  parts  each  of  stone  and  sand. 
Terrazzo,  or,  as  they  are  more  commonly  known,  Hake  mosaic, 
floors  in  the  present  form  arc  made  of  cement  instead  of  Liu  e 
mortar,  colored  if  desired  (this  to  be  done  with  mineral  colors 
only,  as  they  are  unfading),  into  which  is  put  broken  marble, 
either  pure  while  or  in  colors.  The  cement  should  he  best  Port- 
land, thoroughly  mixed  with  one  part  of  sand,  and  the  broken 
marble  put  into  this,  in  pieces  not  less  than   >  ,    inch  thick  and  no 


FLOORS  AND  WAINSCOTS  6i    > 

larger  than  %  inch,  in  sufficient  quantity,  so  that  the  [(articles  lie 
close  together  in  the  floor.  The  cement  should  first  be  water- 
proofed (as  described  elsewhere)  by  mixing  into  the  cement  ma- 
terials specially  prepared  for  this  purpose.  These  prevent  water, 
acid  or  oil  stains  on  the  floor,  and  make  them  so  that  they  are 
easily  cleaned.  They  do  not  affect  the  setting  or  hardening 
quality  of  the  concrete  and  prevent  efflorescence.  After  this  con- 
crete is  put  into  place  and  thoroughly  tamped  down,  it  must  be 
brought  to  the  proper  level  and  left  to  set  about  twelve  hours  and 
then  rubbed  with  standstone  to  a  true  and  level  surface.  It  is 
then  allowed  to  thoroughly  set  again,  rubbed  and  finally  polished. 

These  floors  need  not  be  laid  continuously,  especially  in  cor- 
ridors. 

It  is  recommended  that  expansion  joints  be  put  in  the  work, 
especially  in  steel  constructed  buildings,  so  that  if  there  is  any 
settling  of  the  building  no  cracks  will  occur,  but  that  the  cleavage 
will  go  along  the  lines  of  these  joints,  which  can  then  be  grouted 
or  filled  with  cement.  These  joints  can  be  made  of  tiie  or  of  mar- 
ble in  tile  shape,  about  three-fourths  inch  square. 

If  the  cement  has  not  been  waterproofed,  the  Moors  should  be 
treated  with  a  coating  of  cement  filler  and  then  cement  floor  paint. 
Floors  so  treated  are  impervious  to  water  or  oil.  This  prevents 
disintegration  of  the  cement  surface  and  dust  produced  by  fric- 
tion of  shoe  soles.  This  process  is  not  as  economical  as  the  water- 
proofing process,  as  it  is  necessary  to  repaint  the  floors  frequently. 

These  floors  are  used  in  corridors,  entrance  halls,  operating 
and  dressing  rooms,  recovery  rooms,  toilet  rooms,  laboratory  and 
public  offices,  waiting  rooms,  kitchens  and  kitchen  stoic  rooms. 

Tile. — Tile  floors  are  made  of  vitreous  'tile,  which  come  in 
square,  round,  hexagonal  and  octagonal  forms.  These1  can  be  pui 
into  floors  in  combination  and  in  colors.  They  run  in  size  from 
three-fourths  inch  to  the  large  red  and  white  tiles  six  and  eight 
inches  in  size.  The  two  and  three  inch  hexagonal  tile  make  the 
most  satisfactory  floors.  The  base  for  these  is  the  same  as  for 
the  flake  mosaic  variety.  The  tile  are  laid  in  cement,  grouted  to 
true  and  level  lines,  and  after  they  are  set  the  joints  are  grouted. 
The  grouting  for  laying  tile  is  made  of  two  parts  of  Portland 
cement  and  three  parts  of  clean,  sharp  sand.  The  grouting  for 
joints  is  made  with  clear  Portland  cement  and  must  be  cleaned  off 
the  face  of  tile  before  it  sets.  If  there  is  any  settlement  in  the 
building  the  line  of  separation  between  tiles  can  lie  easily  re- 
grouted.  The  tile  are  impervious  to  water  and  oil.  Tile  Soors 
when  installed  are  used  in  the  same  spaces  designated  U>v  flake 
mosaic  floors. 


.' ,74  FLOORS  AND  WA 1  N  S(  OTS 

Glass. — Glass  for  floors  has  many  advantages  over  other 
Conns,  as  well  as  some  disadvantages.  It  is  impervious  to  water, 
oil  and  acids.  It  comes  in  large  pieces  and  thus  allows  a  minimum 
of  joints  in  such  floors.  Its  great  disadvantage  Lies  in  the  fact 
that  it  chips  very  easily,  and  heavy  objects  dropped  on  it  at  a 
coiner  or  on  an  edge  break  it  or  chip  it  at  such  a  point.  In  such 
instances  there  is  no  manner  by  which  the  damage  can  be  remedied 
except  to  replace  the  entire  slab.  The  floor  in  "hone''  finish,  that 
i-.  ground  or  sand  blasted  to  a  mat  finish,  does  away  with  the  pos- 
sibility of  a  slippery  surface — that  is,  it  is  no  more  so  than  a  tile 
or  mosaic  floor.  This  form  is  extremely  expensive  compared  with 
flake  mosaic,  and  while  it  has  many  advantages  over  the  latter,  it 
has  decidedly  greater  disadvantages..  It  is  laid  in  cement  in  the 
same  manner  as  tile  is  laid.  Thus  far  it  has  only  been  used  in 
operating  rooms  and  toilet  rooms. 

Marble. — Marble  for  floors  in  hospitals  is  not  to  be  recom- 
mended. It  is  soft  and  wears  unevenly.  It  is  absorbent  to  a 
great  extent,  and  when  once  discolored  cannot  be  thoroughly 
cleaned.  It  has  the  disadvantage  moreover  of  slowly  discoloring 
turning  yellow  with  age.  Owing  to  its  coarse  and  granular  tex- 
ture it  breaks  readily  and  must  be  replaced,  as  it  cannot  be 
patched. 

Slate  and  Stone. — Slate  and  stone  of  slate  variety  type  can 
he  used  for  floors,  but  owing  to  the  color  they  are  not  desirable. 
They  can  be  used,  however,  in  toilet  rooms,  where  they  are  prefer- 
able to  marble  or  glass,  as  they  are  practically  impervious,  and 
have  the  added  advantage  of  being  economical  both  in  first  cost 
and  in  subsequent  repairs. 

Composition  Floors. — There  are  many  floors  of  this  charac- 
ter which  are  meant  to  take  the  place  of  marble,  tile  or  flake 
mosaic.  They  have  been  used  to  some  extent,  but  the  majority 
of  them  are  of  too  recent  introduction  to  warrant  their  recom- 
mendation. There  are  several  of  these  made  on  a  cement  basis 
with  other  materials,  and  may  be  obtained  in  a  multitude  of  colors. 
In  one  form  instead  of  using  marble  for  the  flake  effect,  broken 
-hells  are  used,  and  the  appearance  of  the  floor  is  very  satisfac- 
tory. It  is  claimed,  and  reasonably  so.  that  the  floor  with  shells 
is  superior  to  a  floor  with  marble  Hake,  inasmuch  as  the  former  is 
impervious  and  sanitary,  while  the  marble  is  absorbent. 

There  are  also  floors  which  are  made  on  a  composition  base 
thai  contain  small  particles  of  wood,  intimately  mixed  into  the 
mass.  It  is  claimed  for  these  that  they  are  quieter  and  warmer 
than  the  /ordinary  cement,  tile  or  composition  floor,  but  it  is  doubt- 
ful  whether  this  claim   would  justify  the  use  of  a   floor  in  which 


FLOORS  AND   WAINSCOTS 


375 


a  material  as  easily  destructible  as  coarse  sawdusl   enters,  and 
which  would,  in  a  short  time,  have  the  wearing  surface   pitted, 

thus  making  a  place  for  the  lodgment  of  organic  and  inorganic 

particles. 

There  is  also  on  the  market  another  composition  fl<»<  r  whicn 


fig.  226. 
is  treated  with  oil  and  polished  much  in  the  same  way  as  wood 
floor.     It  is  claimed  that  it  is  absolutely  sanitary  and  has  excel- 
lent wearing  qualities. 

Floors  in  toilet  and  bathrooms  should  be  thoroughly  water- 
proofed in  the  same  manner  as  described  for  basement  floors. 

^4 


i  ,.;.  -It. 

Coves.— The  connection  between  floors  and  walls  and  wains- 
cots in  all  hospitals  should  be  in  cove  form  throughout.     This 
not  primarily  so  much  to  guard  againsl  micro-organisms  as  it  is 
to  favor  absolute  cleanliness.    Sharp  angles  and  corners  along  the 


376 


FLOORS  AXD  WAINSCOTS 


floor  line  cannot  but  be  a  collecting  place  for  dust  and  dirt,  which 
the  utmost  care  and  cleaning  will  not  wholly  dislodge.  A  cove  can 
be  mopped  as  readily  as  the  remainder  of  the  floor.    Elsewhere  in 


the  manner  of  putting  these  into  the  building.     The  materials  for 
making  these  coves  are  numerous.     In  rooms  and  wards  they  can 


pig.  229. 
l»c  made  of  wood,  as  shown  it!  Pigs.  33  to  36,  or  they  can  be  formed 
by  the  plaster,  as  shown  in  Fig.  161.   This  applies  particularly  to 
coves  in  connection  with  wood  floors,  either  covered  or  uncovered 


FLOORS  AND  WAINSCOTS 


377 


Coves  of  cement,  marble,  tile,  glass,  slate  and  composition  can  be 
used  in  place  of  such  wooden  coves,  but  the  cement  or  composition 
coves  are  fully  as  good  as  the  more  expensive  ones.  Coves  in 
connection  with  floors  made  of  mosaic,  tile,  marine  or  glass  can 
be  of  any  of  these  materials;  glass  floors  also  should  be  equipped 
with  glass  coves  if  the  wainscots  were  also  of  glass.  This,  it  rrtighl 
be  stated,  is  not,  strictly  speaking,  a  cove,  but  is  put  in  as  shown 
in  Fig.  226,  and  has  very  wide  angles.  The  floors  can  be  equipped 
with  tile  coves  which  are  made  in  patterns  from  the  small  two-inch 
radius  cove  to  the  cove  and  base  combined,  as  shown  in  Figs.  227- 
228.  Flake  mosaic  floors  are  ordinarily  equipped  with  coves  made 
of  the  same  material,  cast  in  lengths  of  about  four  to  six  feet,  or 
run  in  molds  continuously  in  place.  This  also  applies  to  the  compo- 


fig.  230. 

sition  and  all  cement  coves.  It  is  more  satisfactory  to  have  the 
molds  made  and  set  than  to  run  them,  as  they  can  then  be  machine 
rubbed  and  the  surfaces  made  more  even  and  true.  Slate  Moors 
would  have  coves  of  the  same  material,  of  soapstone  or  cement. 
These  soapstone  and  slate  coves  are  machine  made,  are  admirable 
in  all  ways,  and  are  recommended  for  rooms,  wards,  toilet  rooms 
and  even  corridors,  in  connection  with  any  kind  of  floor  where 
darker  colored  floors  are  used.  They  are  absolutely  sanitary  and 
impervious.  Marble  coves  are  not  impervious  ami  oxcepl  where 
marble  wainscots  are  used  in  connection  with  floors  of  the  same 
material  are  not  recommended,  as  they  are  liable  t<>  be  broker  and 
besides  are  quite  expensive. 

Base  Blocks. — Wherever  floor  coves  are  used  the  base  blocks 


378 


FLOORS  A  X  I  >    W  \  1 N  SCOTS 


-hould  be  of  the  same  material  as  the  coves,  and  should  be  so 
designed  that  they  form  no  sharp  corner  with  the  cove  for  the  lodg- 
ment of  dirt. 

Wainscots  and  Walls. — These  can  be  made  of  cement,  slate, 
soapstone,  tile,  marble  or  glass,  dependent  usually  upon  the  space 
in  which  they  are  to  be  placed.  Operating  rooms  are  ordinarily 
equipped  in  tile,  glass  or  marble,  the  height  usually  depending 
upon  the  amount  which  can  be. expended  for  this  portion  of  the 
work.  Marble  is  not  wholly  satisfactory,  owing  to  the  fact  that  it 
is  easily  scratched  and  marred,  and  also  because  it  turns  yellow 
under  repeated  cleaning,  such  as  is  administered  in  operating 
rooms.  Tile  is  impervious,  does  not  mar  or  scratch,  bui  is  subject 
to  crazing.  It  has  also  the  disadvantage  of  having  numerous 
joints,  but  if  these  are  properly  filled  with  waterproofed  cement 


FIG.  231. 

grouting,  this  is  not  a  serious  objection'.  Tile  should  be  put  on 
wet  over  a  Portland  cement  base  and  should  always  be  of  the  lock 
back  pattern,  as  shown  in  Fig.  230.  Glass  Tor  wainscots  is  prac- 
tically a  new  product.  This  glass  is  milk  white  and  is  absolutely 
impervious  and  acid  proof,  as  it  is  made  like  ordinary  plate  ulass 
and  polished  in  the  same  manner.  The  chief  objection  to  this 
material  is  its  liability  to  chip  in  setting,  its  liability  to  show  stains, 


FLOORS  AND   WAINSCOTS 


379 


and  its  present  high  cost  of  installation.  "Hone"  finishes  should 
never  be  used  on  wainscots  of  this  material,  as  they  soil  too  easily. 
For  corridors,  cement,  tile,  glass  and  marble  are  most  often 
used,  but  the  cement  and  tile,  except  for  corridors  in  the  operat- 
ing department,  are  fully  as  good  as  those  made  of  other  materials, 
V/ 


Glass. 


FIG.   -••-. 


Marble. 


Tih 


.•ind  have  the  advantage  of  being  less  expensive.  Th<-  cemenl 
wainscot  could  be  painted  or  enameled,  and  in  all  corridors,  ex- 
cept as  mentioned  and  OD  the  first  floor,  this  would  in  no  way 
detract  from  the  value  of  this  material  for  a  wainscot.     The  wain- 


380  FLOORS  AND  WAINSCOTS 

cot  on  the  first  floor  of  a  hospital  is  usually  of  other  materials 
than  cement  for  esthetic  reasons,  and  not  because  they  are  more 
adaptable.  In  kitchens  and  nurses'  rooms  cement  wainscots  arc 
admirable,  although  tile  can  be  used.  Marble  should  never  he 
used  in  these  rooms,  as  it  absorbs  any  Liquid,  acid  or  grease  which 
i-  put  upon  it.  In  toilet  rooms,  wainscots  ami  partitions  can  be 
made  of  marble,  slate,  soapstone,  rough  wire  glass  and  the  white 
glass.  All  partitions  should  be  put  up  in  such  a  manner  that  the 
entire  door  is  as  nearly  clear  of  obstruction  as  possible.  Fig.  231 
shows  a  partition.  The  standards  for  raising  these  partitions, 
except  those  of  wire  glass,  are  of  nickeled  brass  or  white  metal. 
A  <-ap  mold  can  be  run  over  these  partitions  in  order  to  give  them 
the  necessary  rigidity  and  support,  but  the  nickeled  brass  or  white 
metal  tube,  as  shown,  is  preferable,  as  it  is  stronger  and  stirrer 
than  the  partition  material.  Wire  glass  partitions  are  made  of 
angle  iron  frames,  the  glass  being  set  in  these  frames.  This  parti- 
tion has  the  great  advantage  over  those  made  of  all  other  mate- 
rials in  that  it  permits  the  maximum  amount  of  light  to  penetrate 
into  all  spaces  in  the  toilet  room  divided  by  these  partitions. 
There  is,  however,  a  serious  objection  to  the  use  of  this  material 
for  partitions  in  bathrooms,  because  the  outlines  of  the  bather's 
body  ean  be  recognized  through  these  partitions  if  the  bathroom 
is  Lighted  artificially  at  night,  The  wainscot  in  these  toilet  rooms 
can  be  of  slate,  soapstone,  marble  or  tile,  or  the  entire  walls  can 
be  of  cement  and  thoroughly  enameled.  All  wainscots  should 
have  rounded  coiners,  as  shown  in  Fig.  232.  In  operating  rooms 
rooms  the  door  ami  window  jambs  and  trim  can  also  be  made  of 
the  same  material  as  the  wainscot  of  the  room.  Sills,  as  men- 
tioned elsewhere,  should  be  of  materials  other  than  wood. 


CHAPTER  XXII. 

ILLUMINATION. 

In  treating  this  subject  the  different  methods  in  use  will  be 
given  and  as  far  as  possible  the  hygienic  effects  of  each  will  be  set 
forth.  These  latter  are  principally  quoted  from  papers  on  the 
subject  by  physicians  who  have  made  investigations 

The  difference  between  light  and  illumination  should  be  care- 
fully noted.  Light  is  a  cause;  illumination  an  effect.  An  object 
on  which  light  falls  becomes  illuminated.  Illumination,  therefore, 
is  the  result  produced  by  light.  An  object  is  well  illuminated  when 
it  can  be  easily  seen  without  fatigue  or  strain  on  the  eyes.  Good 
illumination,  therefore,  requires  several  things,  among  which  may 
be  mentioned : 

1.  Sufficient  light  to  enable  one  to  see  clearly  and  distinctly. 

2.  Avoidance  of  too  much  light,  which  produces  a  blinding 
and  fatiguing  effect  on  the  eye. 

3.  Avoidance  of  having  a  bright  light  in  the  field  of  vision, 
which  cuts  down  the  ability  to  see  clearly  things  which  are  less 
brilliantly  illuminated. 

4.  Avoidance  of  streaks  or  striations,  which,  however,  are 
more  noticeable  with  electric  than  with  gas  lights. 

5.  A  steady  light — i.  e.,  avoidance  of  a  flickering  light,  like  an 
open  flame  burner  with  insufficient  draft,  which  quickly  tires  even 
the  strongest  of  eyes. 

(!.  Avoidance  of  regular  reflection,  which  is  commonly  known 
as  glare,  due  to  the  light  striking  an  object  at  such  an  angle  that 
a  large  part  of  the  light  is  reflected  directly  into  the  eyes. 

7.  Avoidance  of  too  sharp  contrasts,  such  as,  for  instance,  a 
brilliantly  lighted  desk  with  the  rest  of  the  room  in  darkness. 

From  the  foregoing  it  will  be  seen  thai,  in  considering  any 
form  of  illumination,  it  is  absolutely  necessary  to  take  into  consid- 
eration the  effect  on  the  eye.  Nature  has. given  us  in  the  eye  a 
wonderful  and  delicate  camera,  which,  with  proper  care,  can  be 
used  indefinitely,  but  which,  with  the  introduction  of  lights  of  liiii.li 
intrinsic  brilliancy,  we  have  shamefully  misused. 

In  dealing  with  modern  sources  of  light  it  is,  therefore,  uec 
essary  to  take  into  account  the  effect  of  the  same  on  the  eye,  and 


382  ILLUMINATION 

in  every  ease  reduce  the  intrinsic  brilliancy  as  far  as  possible. 
With  electric  incandescent  lamps  it  is  possible  sometimes  to  con- 
ceal them  entirely  from  view,  thus  getting  indirect  illumination. 
which  is  generally  satisfactory,  except  from  the  standpoint  of 
economy.  With  gas  such  treatment  is  usually  out  of  the  question, 
although  not  always  so,  and  we  should,  therefore,  place  our  lights 
high  enough  to  be  out  of  the  Held  of  vision  wherever  possible,  and 
to  use  diffusing  globes,  which  not  only  cut  down  the  intrinsic  bril- 
liancy, and,  therefore,  make  it  possible  to  see  with  much  more  com- 
fort, but  actually  enable  us  to  see  more  clearly,  owing  to  the  eye 
being  enabled  to  work  with  a  wider  aperture.  It  is,  therefore, 
necessary  to  study  the  effects  not  of  the  light  alone,  but  with  the 
glassware  which  it  is  desired  to  use.  The  absorption  or  loss  of 
light  due  to  the  surrounding  globes,  as  well  as  their  distribution, 
must  be  considered. 

In  addition  to  the  above  requirements  the  following  also  must 
be  taken  into  consideration : 

First — The  plan  of  the  floor  and  height  of  ceilings  as  laid  out 
by  the  architect. 

Second — The  purpose  for  which  the  various  rooms  are  to  be 
used. 

Third — The  luminant,  or  means  of  producing  the  light. 
Starting  from  these  fixed  conditions  we  must  determine : 
First — The  requisite  intensity  of  illumination  on     some     as- 
sumed or  real  surface  in  each  room. 

Second — The  location  of  the  light  sources. 
Third — -The  candle  power  and  distribution  of  the  light  units. 
The  first  condition  to  be  settled  is  the  question  of  intensity  of 
illumination.  It  is  on  this  particular  point  that  the  lay  mind  is 
usually  most  seriously  confused,  owing  largely  to  the  loose  and 
ambiguous  manner  in  which  the  various  terms  of  expressing  light 
measurements  are  used.  The  term  "candle-power';  suggests  at 
least  a  definite  idea,  on  account  of  the  familiar  Ki-candlo-power 
electric  lamp;  but  the  term  "foot  candle"  is  absolutely  meaning- 
less to  the  layman  and  expresses  but  a  vague  idea  to  the  average 
architect  or  engineer;  yet  it  is  precisely  this  measurement  that 
is  the  foundation  and  starting  point  in  practical  illuminating  en- 
gineering. 

The  apparent  brightness  of  intensity  of  illumination  of  the 
surface  as  seen  hy  the  eye  depends  not  only  upon  the  amount  of 
light  falling  upon  the  surface,  but  upon  the  amount  of  light  which 
the  surface  reflects  to  the  eye.  Scientifically  expressed,  it  depends 
upon  the  brilliancy  of  the  image  on  the  retina.  This  visual  inten- 
sity, which  i<  the  final   result   that   we  are  after,   is,  therefore,  the 


ILLUMINATION  383 

intensity  of  illumination  received,  multiplied  by  the  co-efficient  of 
reflection  of  the  surface  illuminated.  This  simple  fact  is  often  lost 
sight  of  in  estimating  the  intensity  of  illumination  required. 

The  prime  factors  in  determining  this  question  of  intensity 
are.  therefore,  the  purpose  for  which  the  room  is  to  be  used,  and 
the  color  of  the  surfaces  which  are  the  special  objects  of  the 
illumination;  having  these  given,  the  determination  then  is  a 
matter  of  judgment  based  upon  actual  experience. 

According  to  Fechner's  law.  the  human  eye  can  perceive  a 
fixed  fractional  difference  of  illumination,  irrespective  within  wide 
limits  of  its  absolute  amount.  This  fraction  varies  in  general  from 
about  1  per  cent,  to  about  .55  per  cent.,  assuming  ordinary  sources 
of  illumination  and  normal  eyes. 

Now  for  the  purpose  of  practical  lighting  the  illumination 
should  be  generally  kept  within  the  range  for  which  Fechner's  law 
holds  good,  and  once  well  within  that  range  of  normal  sensibility 
nothing  is  gained  virtually  by  increasing  the  strength  of  the 
illumination,  so  far  as  difference  of  luminosity  is  concerned. 

Tt  therefore  plainly  appears  that  at  1  or  '2  foot  candles  the 
eye  is  working  so  near  its  normal  sensibility  that  further  increase 
in  illumination  is  of  relatively  very  small  value. 

The  essential  point  on  good  seeing,  however,  is  that  the 
values  here  specified  should  be  those  affecting  the  eye  and  not 
merely  those  by  which  objects  are  illuminated. 

Since  objects  are  seen  in  virtue  of  differences  of  reflected 
light  the  illumination  which  affects  the  eye  is  determined  by  the 
co-efficients  of  diffuse  reflection  of  the  objects  in  the  field  of  view. 

As  stated  above,  any  violent  contrast  in  the  field  of  vision  is 
objectionable,  so  that  if  conditions  are  such  as  to  require  powerful 
illumination  in  a  part  of  the  field  a  very  bright  background  in  the 
rest  of  the  field  should  be  avoided,  it  being  preferable  to  have 
there  merely  enough  light  to  avoid  excessive  contrasts. 

As  most  objects  are  colored,  the  relative  Luminosities  <>t  vari- 
ous colors  are  important  considerations  in  illumination,  and  that 
the  eye  is  affected  by  various  colors  in  very  different  degrees  is 
well  known.  The  luminous  part  of  the  spectrum  lies  mainly  be- 
tween wave-lengths  700  mm.  and  400  mm.,  the  effective  pail  of  it 
lies  between  w.  1.  630  and  530.  Energy  outside  these  limits  is  for 
the  most  part  wasted  so  far  as  vision  is  concerned. 

At  first  sight,  therefore,  the  eye  would  seem  to  he  very  ineffi- 
ciently organized.  Such,  however,  is  not  the  case,  for  the  eye  has 
been  evolved  not  for  artificial  light,  but  to  meet  the  exigencies  of 
natural  light,  and  its  point  of  maximum  luminosity  falls  very  near 


384  ILLUMINATION 

to  the  point  of  maximum  energy  of  the  solar  light;  iii  fact,  between 
that  and  the  maximum  energy  point  for  .skylight,  so  that  the  ad- 
justment of  the  sensibility  for  natural  conditions  is  excellent. 

Moreover,  were  it  not  for  the  adjustment  of  the  eye  for  a 
-harp  maximum  of  sensibility,  we  should  be  totally  unable  to  see 
clearly  on  account  of  the  effect  of  chromatic  aberration.  When 
the  eye  is  accommodated  for  yellow  light  images  due  to  deep  red 
and  deep  blue  light  are  badly. out  of  focus,  and  were  they  com- 
parable in  brightness  to  the  yellow  image  near  vision  would  be 
very  indistinct,  and  aside  from  this  we  should  lose  much  of  the 
contrast  which  helps  to  render  objects  visible.  As  was  long  ago 
noted  by  PurMnje  and  Dove,  the  relative  luminosity  of  different 
colors  is  greatly  affected  by  the  absolute  intensity  of  the  illumina- 
tion. 

The  flaming  arc  is  one  of  the  most  efficient  illuminants  yet 
found.  But  the  light  has  a  large  color  error  which  can  be  cor- 
rected only  by  a  considerable  sacrifice  of  efficiency. 

Could  one  steal  the  firefly's  secret  the  result  would  be,  if  Lang- 
ley's  experiments  correctly  represent  it,  a  light  of  high  efficiency, 
it  is  true,  but  of  about  the  color  of  a  superannuated  Welsbach. 

ILLUMINATING  WITH  GAS. 

Gas  as  an  illmninant  is  rapidly  decreasing  owing  to  the  intro- 
duction of  electric  lighting  and  the  reduction  in  price  of  the  latter. 
But  however  much  this  reduction  may  be,  the  open  flame  burner 
will  be  used  for  years  to  come  and  gas  for  illumination  will  prob- 
ably never  be  wholly  replaced  universally.  The  electric  light  is 
more  adaptable,  requires  less  care  and  produces  less  heat;  to 
oifset  these  advantages,  gas  light  is  much  more  economical. 

Having  an  economical  advantage  so  largely  in  its  favor  and 
apparently  unattainable  by  any  system  of  electric  lighting,  gas 
lighting  has  rested  upon  this  single  point  of  superiority,  and  as 
a  result  it  has  assumed  a  secondary  place  in  illumination;  that  is. 
it  is  used  where  electric  lighting  cannot  be  afforded  or  obtained. 
Recent  discoveries  in  the  production  of  electric  light  are  of  so  revo- 
lutionary a  nature  as  to  very  seriously  threaten  this  chii  f  vantage 
ground  of  gas  lighting.  The  same  principles  which  have  been 
utilized  in  the  cheapening  of  gas  light — that  is,  the  use  of  the 
peculiar  properties  of  the  so-called  rare  earths  and  metals — are 
at  la-t  being  appropriated  by  the  electrical  interests,  with  the  cer- 
tain!} that  in  the  near  future  the  efficiency  of  electric  lighting  will 
lc  .it  least  doubled. 

The  simplest  form  of  gas  lighting  and  the  one  with  which  all 


ILLUMINATION  38o 

are  most  familiar  is  the  old  gas  tip — either  of  the  lava  or  steel 
form.  This  needs  no  special  mention,  but  a  few  words  as  to  the 
size  and  use  of  these  may  be  of  assistance  if  such  are  used. 

Burners  should  be  in  line  with  the  center  of  the  fixture.  This 
gives  all  of  the  light  and  does  not  to  any  extent  injure  the  effect. 

A  source  of  insufficient  lighting  is  often  found  in  the  imitation 
candles  with  small  tips  which  are  put  on  fixtures. 

It  might  seem  that  in  changing  the  tip  from  a  smaller  to  a 
more  efficient  burner  that  the  bills  for  consumption  of  gas  would 
be  increased,  but  this  is  not  true,  for  if  a  standard  open  name 
burner  is  used  and  this  be  taken  off  and  a  small  tip  burner  be 
substituted,  it  will  be  found  in  comparison  for  the  amount  of 
illumination  given  that  the  standard  flame  burner  will  consume 
about  half  the  amount  of  gas  which  would  be  necessary  to  give 
the  same  illumination  with  the  smaller  tip.  All  tips,  however, 
must  be  kept  clean  and  only  those  used  which  are  approved  and. 
have  been  proven  to  be  efficient. 

Incandescent  Mantles. — The  form  of  gas  lighting  most  com- 
monly used  at  present  is  with  the  incandescent  mantle.  These  are 
to  be  obtained  in  almost  any  size,  shape  and  quality.  In  fact,  it 
has  been  confusing  so  rapid  has  been  their  increase.  They  are  all, 
however,  of  the  same  general  pattern  so  far  as  their  lighting  qual- 
ity is  concerned. 

The  earlier  forms  of  these  was  the  AVelsbach  burner,  with  tall. 
straight  chimneys,  and  small  fluted  porcelain  reflectors  and  were 
hopelessly  ugly.  Add  to  this  the  greenish  cast  of  the  light  which 
the  mantles,  particularly  when  old,  gave  forth,  and  their  excessive 
glare,  and  the  combination  made  a  very  poor  second  to  the  com- 
parative elegance  of  the  incandescent  lamp  with  its  usually  small 
or  less  ornamental  shade.  Later  an  attempt  was  made  to  imitate 
the  most  effective  form  of  electric  lamp,  so  far  as  appearance  is 
concerned,  that  is  the  arc  lamp. 

Globes. — A  source  of  ineffectiveness  in  lighting,  as  well  as 
an  additional  cost  for  lighting,  has  been  found  in  the  pattern  and 
color  of  the  light  or  of  the  globes  which  are  used,  the  latter  pi-<>l> 
ably  for  some  decorative  effect.  Undoubtedly  people  will  con- 
tinue to  use  schemes  of  interior  decoration  when  utility  should  be 
their  first  consideration.  As  stated  herein,  the  best  type  of  globe 
for  illumination  in  hospitals  is  some  kind  of  scientific  prismatic 
globe,  which  has  been  given  proper  amount  of  study.  In  all  in- 
stances the  manufacturers  of  such  globes  should  be  consulted  if 
the  lighting  is  not  attended  to  by  the  architect,  who  would,  of 
course,  specify  the  proper  globe  to  be  used  lor  the  specific  form 
of  lighting  intended  in  any  given  space. 


38G  ILLUMINATION 

If  gas  is  t<>  be  installed  ami  used,  the  following  will  be  of  spe- 
cial value: 

The  average  consumer  scons  to  have  no  idea  of  the  loss  in 
effective  illumination  through  the  use  of  unsuitable  giobes.  It  is, 
of  course,  well  to  utilize  globes  to  soften  light,  but  not  to  obscure 
and  reduce  illumination.  It  is  strange  that  with  all  the  very  ap- 
parent advantages  of  the  Ilolophane  globes  and  shades,  they  are 
hut  little  used  on  this  side  of  the  Atlantic. 

A  source  of  criticism  has  been  found  in  the  use  of  globes  where 
the  bottom  openings  were  of  small  diameter;  the  drafts  up  through 
the  globes  due  to  these,  set  the  open  flame  burners  dickering  badly, 
causing  eye  weariness,  and  in  many  eases  the  substitution  of  even 
oil  Lamps  to  overcome  this.  Under  no  circumstances  whatever 
should  the  old  type  of  globe  be  used.  We  often  see  the  user  of 
illuminants  start  out  with  clean  appliances,  ami  as  they  become 
clouded  with  dirt  they  have  to  double  the  unit  of  light  in  use  and 
then  condemn  the  purveyor.  If  ordinary  clean  glass  obstructs  10 
per  cent,  of  light,  and  opal  globes  60  to  70  per  cent.,  imagine  the 
Loss  of  light  and  the  cost  of  lighting  when  chimneys  or  bulbs  build 
upon  their  surfaces  successive  laminations  of  opalescence.  It 
does  seem  strange  that  it  is  necessary,  in  this  age,  to  prove  that 
it  pays  to  keep  clean.  This  loss  of  light  due  to  fouling  of  globes 
is  very  much  more  serious  where  ground  glass  globes  or  opaL 
globes  are  used,  than  with  clear  glass;  as  the  fouling  is  so  grad- 
ual and  so  near  the  color  of  the  globes  themselves  that  it  takes 
months  before  they  become  noticeably  dirty.  In  the  meantime 
additional  units  of  light  are  brought  into  use  and  expense  increased 
to  the  consumer. 

Without  disparaging  the  inverted  burner,  it  may  be  safely 
asserted  that  the  upright  incandescent  gas  lamp  can  be  made  quite 
as  decorative  and  elegant  in  appearance  as  the  incandescent  elec- 
tric lamp.  It  is  worth  remarking  also  that  while  the  gas  lam)) 
manufacturer  has  been  struggling  to  turn  his  lamp  downward  after 
the  fashion  of  some  electric  lamps,  the  electrical  fixture  makers 
and  decorators  have  been  turning  their  electric  lamps  upward  in 
.-in  endeavor  to  imitate  candles  and  gas  flames. 

HOLOPHANE  GLOBES. 

The  Holophane  System  is  used  largely  in  hospital  lighting, 
owing  to  the  fact  that  the  globes  give  practically  as  good  diffusion 
,i-  opal,  with  a  very  small  loss  by  absorption,  being  only  about  12 
per  cent,  on  the  average,  and  at  the  same  time  having  the  properly 
of  directing  the  Lighi  in  directions  wanted.  In  general  they  are 
made  in  three  types : 


ILLUMINATION 


::s: 


Class  A.  to  throw  the  maximum  light  directly  down. 

(Mass   I>.  for  spreading  the  light  uniformly  below  the  liori 

zontal. 

Class  C,  to  throw  the  light  sideways. 


fig.  233. 


Fig.  233  shows  a  Class  A  globe  designed  for  a  mantle  burner. 
Fig.  234  shows  a  Class  B  globe. 

Fig.  235  shows  a  Class  C  globe,  all  intended  for     standard 
burners. 


pig    234. 

Fig.  236  shows  a  Class  A  stalactite  for  electric  light,  intended 
for  use  where  it  is  desired  to  throw  the  strongest  light  directly 
downward. 


pig.  235. 

Fig.  237  shows  ;i  pendant  ball  designed  for  general  distribu- 
tion of  light. 

Fig.  238  shows  a  pendant  open  globe  for  general  distribution. 
Fig.  23>!)  shows  -,\  globe  for  brackel  lighting  which  is  designed 


388  ILLUMINATION 

with  reflecting  prisms  on  the  back  so  that  but  little  light  reaches 
the  wall,  the  majority  being  thrown  out  into  the  room. 

Fig.  240  shows  an  upright  globe  for  general  distribution  of 
light. 


fig.  236. 

Fig.  241  shows  a  globe  for  the  ordinary  Mat-flamed  burner, 
intended  for  general  distribution  of  light. 
Fig.  242  shows  another  form  of  globe. 


fig.  237. 

Holophank  lii:  i  lectors. — These  reflectors,  which  .have  become 
such  an  important  adjunct  in  lighting,  are  made  at  present  only 
for  electric  Lights. 


fig.  238. 

Fig.  243  shows  a  form  of  reflector  for  throwing  the  light 
strongly  downward,  giving  no  less  than  56  C.  P.  directly  under- 
neath the  reflector  when  equipped  with  a  16  C.  P.  lamp. 

Fig.  244  shows  a  reflector  for  throwing  a  strong  light  sideways 


ILLUMINATION  389 

and  is  designed  to  give  uniform  illumination  over  a  large  area  at 
the  same  time  being  deep  enough  to  hide  the  lamp  from  view. 

Fig.  245  shows  a  reflector  for  throwing  a  strongly  distributed 
light. 


fig.  239. 

Fig.  246  shows  a  Holophane  Cluster  equipped  with  40  C.  P. 
Gem  high  efficiency  lamps  consuming  the  same  amount  of  energy 
as  an  arc  lamp,  but  giving  considerably  more  illumination  and  ai 
the  same  time  giving  the  soft  light  which  is  so  desirable  in  hos- 
pitals. 


fig.  240. 

Figs.  247,  248,  249  are  types  of  globes,  Fig.  247  giving  a  wide 
distribution,  and  Fig.  248  giving  a  strong  downward  light.  Fig. 
249  is  a  "bowl"  reflector,  which  brings  the  light  down  and  spreads 
it  at  the  same  time. 


no.  241. 

Acetylene. — Acetylene  is  not  recommended  Tor  hospital  light- 
ing, although  it  has  merits  which  would  ordinarily  make  it  an 
ideal  illuminant. 

Horace  Allen  says  as  to  its  demerits: 


390 


ILLUMINATION 


"Though  the  demand  for  acetylene  gas  1ms  steadily  and  con- 
tinually increased  evei  since  calcic  carbide  became  a  commercial 
commodity  several  year.-  ago  through  the  development  of  the 
electric  furnace,  it  is  doubtful  whether  ii  will  ever  seriously  enter 


fig.  242. 

into  competition  with  cither  coal  gas  or  electricity  in  the  field  of 
general  and  economical  illumination  for  public  or  domestic  pur- 
poses or  for  power  development.  The  chief  item  of  expense  being 
for  current,  the  possibilities  in  the  way  of  price  ever  coming-  within 


FIG. 


243. 


the  range  of  competition  are  very  remote  as  Long  as  electricity  is 
employed  in  the  manufacture.  Added  to  the  cost  of  manufacture, 
there  is  necessitated  the  expense  of  packing  in  hermetically  sealed 


fig.  244. 
drums  and  tin  canisters,  owing  to  the  great  affinity  of  calcic  carbide 
for  moisture. 

Pure  acetylene  gas  is  credited  with  having  a  faint,. sweet  smell, 
hut  the  smell  given  off  by  all  the  carbide  th:>  writer  lias  had  the 


ILLUMINATION 


opportunity  to  examine  has  been  quite  the  reverse  of  either  faint 

or  sweet. 

The  unpleasant  odor  arising  from  raw  carbide  upon  opening 
the  receptacle  is  a  primary  source  of  objection,  and  any  neglect 


fig.  245. 
in  the  way  of  resealing  the  drum  after  the  withdrawal  of  the  re- 
quired quantity,  results  in  the  continued  gradual  generation   of 
acetvlene  and  its  objectionable  smell.     For  this  reason  the  besl 


fig.  246. 
place  to  store  carbide  is  al  some  considerable  distance  from  any 
occupied  building. 

To  turn  our  attention   now  to  acetylene,  there  is  no  doubl 


392 


ILLUMINATION 


that  the  light  is  of  high  quality,  both  in  regard  to  illuminating 
power  and  its  preserving  the  natural  colors  of  materials,  etc. 

A  drawback  which  has  given  considerable  trouble  is  the  neces- 
sity for  a  very  fine  orifice  in  the  burner,  but  even  now  while  the 
jet  is  of  such  small  dimensions,  it  is  liable  to  be  stopped  by  the 
slightest  particle  of  dust,  or,  on  the  other  hand,  carbon  becomes 
deposited  and  a  heavy  smoke  flame  results. 


fig.  247. 

To  prevent  the  deposit  of  carbon  at  the  orifice  of  issue  from 
burners,  a  very  common  source  of  trouble,  the  device  of  providing 
duplicate  orifices  at  such  an  angle  that  the  two  issuing  jets  are 
made  to  impinge  upon  each  other  and  form  a  clear  flat  flame,  was 
claimed  to  be  successful. 


FIG. 


248. 


This  class  of  burner  found  much  favor  as  an  improvement 
over  the  single  jet,  but  it  not  unfrequently  happens  that  some 
slight  particle  of  dust  lodges  in  one  of  the  jets  and  deflects  the 
!low  of  gas  to  such  an  extent  as  to  prevent  the  two  jets  meeting 
centrally;  the  result  is  a  very  unsatisfactory  dame,  which  can  only 
be  rectified  by  inserting  a  fine  needle  or  wire  into  the  clogged 


ILLUMIXAHOX 


393 


orifice.  This  would  seem  to  be  a  very  simple  matter,  but  it  must 
be  borne  in  mind  that  the  burner  goes  wrong  just  when  the  light 
is  required,  and  it  is  necessary  for  the  acetylene  gas  tap  to  be 
closed  and  some  other  light  obtained  to  enable  the  clearing  of  the 
burner  to  be  effected,  owing  to  the  minuteness  of  the  hole  in  the 
burner  and  its  angular  direction;  to  insert  the  wire  in  the  orifice 
in  most  burners  is  quite  on  a  par  with  threading  a  needie  with  the 
eye  in  a  rather  inaccessible  position. 

Some  burners  have  the  orifices  in  such  a  position  as  to  render 
it  a  very  delicate  matter  to  clear  them  on  their  becoming  clogged, 
but  the  simplest  way  to  overcome  the  trouble  is  to  provide  spare 
burners,  it  being  an  easier  matter  to  change  the  burner  than  to 
probe  it. 

"While  ordinary  coal  gas  in  course  of  time  reduces  leakage, 
through  deposit,  this  is  not  the  case  with  acetylene,  so  that  all 
joints  must  be  thoroughly  sound  from  the  first. 

In  regard  to  leakage,  the  unpleasant  distinctive  odor  of  im- 


fig.  249. 
pure  acetylene  has  the  advantage  of  quickly  indicating  the  exist- 
ence of  a  leak  and  its  locality.    When  the  gas  is  purified  properly 
there  is  less  evidence,  and,  therefore,  greater  danger  Prom   this 
source  of  trouble. 

Owing  to  its  high  specific  gravity— .9.  or  twice  that  of  coal  gas 
—it  does  not  so  readily  diffuse  and  pass  away,  and  although  the 
smallness  of  the  jets  renders  the  volume  passing  out  in  a  given 
time  considerably  less  than  in  the  case  of  a  coal  gas  burner,  though 
it  must  be  borne  in  mind  that  the  pressure  is  usually  about  twice 
that  required  for  coal  gas,  the  escaping  gas  bangs  round  and  tends 
to  form  an -explosive  mixture  which  would  do  considerable  damage 
if  even  a  smoldering  bit  or  glowing  cigarette  should  bo  broughl 
near,  the  ignition  point  being  only  896  F.,  while  so  small  a.  pro- 
portion of  acetylene  as  3.5  per  cent,  forms  an  explosive  compound 
with  air,  as  compared  with  6  per  cent,  with  coal  gas." 


394  ILLUMINATION 

ELECTEIC  LIGHTING. 

The  use  of  electric  light  is  so  universal  and  nearly  every  one 
is  so  conversant  with  the  ordinary  electric  lighi  that  it  would  seem 
useless  to  describe  systems  and  methods  of  lighting  in  tins  man- 
ner. <  Ordinarily  this  is  true,  but  there  are  so  many  new  methods, 
and  hospital  Lighting  is  so  vital,  that  there  is  need  of  more  detailed 
information  on  the  subject. 

The  placing  of  a  chandelier  in  the  center  of'a  room,  with  one 
or  more  lights  and  an  ordinary  globe,  and  sometimes  colored 
globes,  without  reference  to  the  primary  principles  outlined,  is 
nol  considered  scientific  illumination.  As  has  been  stated,  all 
conditions  must  he  taken  into  consideration.  The  matter  of  the 
position  of  lights;  the  number  of  lights;  their  position  as  regards 
fiic  patient  must  all  he  carefully  figured.  When  these  have  been 
determined,  the  kind  of  light  must  be  taken  as  a  factor.    The  ordi- 


; 


. 
fig.  250. 

Tantalum   Lamp. 

nary  incandescent  lamp  is  no  longer  considered  the  best  form  of 
illuminant,  so   far  as   lighting  by   incandescent  filaments  is  con 
cerned. 

The  new  (i.  E.  M.  lamps,  which  have  a  carbonized  filament, 
mid  the  new  Tantalum  light  arc  bul  two  of  the  Latest  forms  of 
improved  incandescenl  lamp--. 

The  new  (i.  B.  M.  filament  lamp  has  been  standardized  at  50 
watts,  thus  giving  improvement  in  the  form  of  an  increase  in  can- 
dle power  of  25  per  cent,  or  from  16  to  20  C.  P.,  instead  of  a  re- 
duced wattage  to  40  watts  per  lamp.     Its  useful  life  is  750  hours. 

The  Tantalum  lamp  shown  is  the  latest  addition  to  the  science 
of  lighting.     The  Tantalum  lamp  has  a  filament  composed  of  a 


ILLUMINATION 


395 


rare  metal  capable  of  withstanding  very  high  temperatures  out 
of  contact  with  air  and  giving  a  very  brilliant  white  light.  The 
construction  and  general  appearance  and  dimensions  of  the  lamp 
are  clearly  shown  in  the  accompanying  illustration  (Fig.  250). 
The  lamp  is  at  present  supplied  in  but  one  size,  having  a  consump- 
tion of  44  watts  and  giving  a  mean  horizontal  rating  of  22  candle 
power.  It  is  made  for  voltages  of  100  to  130  and  fitted  with  stand- 
ard Edison  base.  The  lamp  should  not  be  used  upon  alternating 
current  circuits. 

As  to  the  best  method  of  lighting  by  these  lamps  experts 
differ  somewhat,  but  in  the  main  the  following  are  regarded  as  de- 
sirable: 


FIG. 


:.i 


For  wards,  lighting  as  shown  in  Fig.  253  is  admirable.  The 
r*"il  lighting  is  done  by  electric  lamps  inside  of  the  inverted  spun 
glass  bowls,  which  are  painted  white  and  covered  with  a  thin  sheet 
of  glass  to  keep  out  the  dust.    The  light  is  reflected  from  the  ceil 


396 


[ILLUMINATION 


Lng  and  from  there  to  the  room.  This  is  a  very  good  example  of 
what  is  commonly  known  as  indirect  illumination,  which  is  highly 
satisfactory  in  such  places.  When  such  a  form  of  lighting  is  used 
there  is  placed  at  each  bed,  or  between  beds,  a  receptacle  into 
which  a  plug  can  be  inserted,  so  that  an  individual  light  can  be 


CM    rt 

»^  :-. 

CM  ^ 

S  s 
'5 

C/i 


used  for  careful  examination  of  patients.  Such  a  light  should  be 
mounted  on  a  stand  and  have  a  flexible  stem  so  that  it  can  be  placed 
in  any  position.  It  should  also  be  equipped  with  a  reflector  and 
a  frosted  lamp. 

The  lighting  of  wards  can  also  be  done  admirably  with  wall 
brackets.  This  enables  the  patient  to  read  in  bed  if  permitted, 
and  also  removes  the  glare  and  intensity  from  the  other  patients. 


ILLUMINATION  397 

Such  lights  should  be  of  about  four  caudle  power  and  have  proper 
reflector  to  protect  the  eyes  of  other  patieuts.  A  wall  receptacle 
could  be  used  instead  of  a  bracket  and  the  light  fastened  by  a 
clamp  to  the  bed.  These  lamps,  moreover,  could  be  equipped  with 
pull  chain  sockets  and  be  turned  on  and  off  very  easily,  or  they 
could  be  equipped  with  lamps  of  the  multiple  pattern,  which  can 
be  turned  on  fully,  with  a  faint  glow,  or  turned  out  by  either  a 
pull  cord  or  a  switch  arranged  for  this  purpose.  Such  lamps  and 
switches  are  now  obtainable  and  are  highly  satisfactory. 

Lighting  of  operation  rooms  can  be  done  in  several  ways  with 
incandescent  lamps.  Fig.  252  shows  a  swing  bracket  with  from 
8  to  16  C.  P.  lamps  and  an  auxiliary  of  gas.  The  objections  to  this 
form  of  lighting  are  the  deep  shadows  owing  to  the  change  of 
position  of  the  operator  and  the  intense  heat  from  the  lamps  owing 
to  the  reflector  over  them. 

Mr.  Ernest  says  in  regard  to  this:  "The  illumination  should 
be  high,  in  foot  candles,  and  shadows  eliminated  as  much  as  pos- 
sible. It  is  also  desirable  to  have  a  light  that  will  give  the  true 
color  to  normal  tissue  so  that  the  surgeon  is  able  to  distinguish 
in  his  operations  the  diseased  from  the  healthy  tissues.  There 
are,  as  a  rule,  two  styles  of  operating  rooms — the  private  and  the 
amphitheater.  In  the  latter  it  is  necessary  to  arrange  the  lights  so 
as  not  to  interfere  with  the  student  body  and  the  operator  and  still 
give  the  required  illumination.  The  surgeon  rarely  operates  in  one 
particular  position  with  relation  to  the  patient  or  the  operating 
table  and,  therefore,  the  light  will  always  have  to  be  placed  so  that 
he  will  not  work  in  his  own  shadow  or  those  of  his  assistant  s. ' 

A&  is  stated  below,  the  possibility  of  shadows  can  be  entirely 
eliminated  by  other  methods  of  lighting. 

The  Sighting  of  the  remainder  of  the  building  must  be  studied 
as  careful  iy  as  is  that  for  wards,  rooms  and  operating  rooms. 
Corridors  can  be  effectively  lighted  by  chandeliers  placed  at 
proper  intervals  so  that  there  are  no  dark  spaces  between.  It  will 
be  necessary,  however,  to  place  the  lights  and  choose  the  globes 
with  reference  to  this.  There  are  other  forms  of  lighting  cor- 
ridors, as  stated  herein. 

VAPOB   LIGHTING. 

The  development  of  lighting  in  general  has  led  to  scientific 
research  along  entirely  new  lines.  It  has  been  stated  by  one  of 
the  experts  making  investigations  that  lie  was  dumbfounded  when 
he  discovered  that  "three-tenths  of  one  per  cent,  of  the  energy 
consumed  is  converted  into  light/' 

It  is  well  recognized,  as  a  scientific  principle,  that  the  most 


398  ILLUMINATION 

efficient  means  for  the  transformation  o['  electrical  into  light  en- 
ergy is  electric  conduction  through  rarefied  gages  or  vapors.  The 
practical  application  of  this  principle  in  one  or  another  form  lias 
occupied  engineers  for  some  years  past,  and  a  mosl  promising  be- 
ginning in  actual  systems  of  this  character  has  recently  been 
made. 

It  was  along  this  line  of  incandescence  that  improvements  had 
to  he  made  and  the  old  principle  of  the  Crook's  tube  w;is  applied. 
The  only  questions  were  the  proper  gas  to  use,  and  the  method 
of  container,  and  the  remainder  would  naturally  follow. 

The  firsl  successful  attempt  to  put  lighting  by  incandescent 
gases  on  a  commercial  basis  was  the  Cooper-Hewitt  light— a  system 
of  mercury  vapor  lighting  with  which  every  one  is  now  familiar. 
That  this  form  of  lighting  is  applicable  for  many  purposes  cannot 
he  doubted,  but  for  the  operating  room  or  general  use  in  hospital 
lighting  it  is  out  of  the  question  in  its  present  form,  owing  to  its 
disturbance  of  reds  in  coloring  schemes.  Wounds  would  take  on 
a  color  distortion  to  which  red  is  subject  under  this  light,  and 
while  it  possesses  a  mild  and  large  glowing  surface  of  great  mag- 
nitude and  has  besides  the  wonderful  low  intrinsic  value  of  incan- 
descent gases,  the  color  objection  cannot  be  waived  in  hospital  use, 
although  the  light  itself  is  practically  available  in  almost  every 
other  case,  with  few  exceptions.  As  in  other  forms  of  vacuum 
tube  systems,  the  great  steadiness  of  the  Cooper-Hewitt  light  is 
noticeable. 

The  Bastiau  mercury  vapor  lamp  is  of  English  origin  and  is 
of  highly  practical  design  for  this  style  of  vacuum  light.  It  is 
in  more  condensed  form  than  the  Cooper-Hewitt,  which  for  ordi- 
nary use  is  an  advantage,  for  the  special  purpose  of  operating 
light  would  not  be  of  much  advantage.  The  combination  of  incan- 
descent lamp  with  the  Bastian  is  possible,  somewhat  eliminating 
the  color  difficulty.  At  present  experiments  are  being  conducted 
on  these  lamps  with  a  view  to  coloring  the  arc  stream  by  the  addi- 
tion of  other  metals  to  the  mercury. 

Probably  the  best  method  so  far  developed  in  vapor  lighting 
is  the  SO-called  Moore  tube.     This  has  been  placed  upon  a  conuner 
cial    basis   and   the   many   installations   of   this    light   attest    to    its 
efficiency,  both  in  the  quality  of  light  and  the  solution  of  attaining 
the  best  light  at  the  least  cost  commensurate  with  its  efficiency. 

The  aature  of  the  Moore  light  is  rather  inaccurately  ex- 
pressed by  the  words  "vacuum  tube  lighting."  Strictly  speaking, 
a  vacuum  is  a  space  void  of  all  ponderable  matter,  and  the  tubes 
which  are  used  in  the  Moore  light  contain  small  quantities  of  mat- 
ter in  the  gaseous  state.    The  basic  principle  of  Ihe  Moore  light  is 


ILLUMINATION 


399 


defined  in  the  most  elementary  books  on  electricity,  wherein  it  is 
stated  that  air  of  the  ordinary  density — that  is,  under  the  ordi- 
nary atmospheric  pressure — is  a  non-conductor  of  electric  cur- 
rents, but  if  the  density  be  reduced  to  a  sufficient  degree,  the  re- 
sistance is  reduced  to  such  an  extent  that  it  may  be  considered  a 
conductor.  The  passage  of  an  electric  current  through  rarefied 
gas  causes  it  to  glow.  The  old  familiar  tube  known  as  the  Crooke's 
tube  exemplifies  these  facts. 

The  Moore  light  of  the  present  time  is  simply  a  glass  tube 
of  convenient  diameter  and  of  any  desired  length,  having  elec- 
trical conductors  hermetically  sealed  into  the  opposite  ends  and 


fig.  253. 
the  air  within  exhausted  to  such  a  degree  as  to  bring  it  to  the 
point  of  conductivity  for  electric  currents  of  available  pressure. 
The  passage  of  the  current  raises  the  rarefied  gases  to  a  state  of 
incandescence.  Any  one  wishing  to  produce  a  Moore  lighl  on  a 
small  scale  can  do  so  by  finding  a  discarded  incandescenl  electric 
lamp  from  which  the  air  has  been  improperly  exhausted,  and  pass 
ing  the  discharge  from  a  spark  coil  through  it. 

As  before  stated,  this  light  consists  essentially  of  a  glass  tube 
having  electrodes  at  opposite  ends  and  containing  ordinary  air 
highly  rarefied.     With  the  continuous  passage  of  an  electric  cur 
rent,  however,  the  air  becomes  gradually  more  rarefied  on  account 


400  ILLUMINATION 

of  electrolitic  action  of  the  gases  in  contact  with  the  electrodes. 
This  increases  the  rarefaction,  and,  as  is  well  known,  beyond  a 
certain  density  any  further  rarefaction  increases  the  electrical  re- 
sistance. Provision  must,  therefore,  be  made  for  maintaining  this 
resistance  at  a  practically  uniform  point;  in  other  words,  of  ad- 
mitting air  to  the  tube  in  extremely  minute  quantities  and  at  reg- 
ular intervals  so  as  to  maintain  a  constant  pressure  of  the  inclosed 
air.  This  is  really  the  crux  of  the  whole  matter.  To  accomplish 
this  a  check  valve  lias  been  invented  which  is  practically  friction- 
less  and  indestructible  and  so  delicate  in  operation  as  to  be  sensi- 
tive to  a  difference  in  pressure  of  1-40,000  of  an  atmosphere. 

This  statement  sounds  like  a  perpetual  motion  '  inventor's 
formula,  but  a  glance  at  the  mechanism  shown  in  the  diagram  will 
at  once  convince  the  reader  that  these  seemingly  impossible  con- 
ditions have  been  accomplished  (Fig.  253). 

The  regulating  apparatus  is  connected  at  6  with  the  vacuum 
tube;  7  is  a  cone  of  carbon  or  other  slightly  porous  material 
tightly  joined  to  the  tube  S.  Around  this  is  an  annular  space 
filled  with  mercury,  11.  Into  this  annular  space  is  dropped  a 
glass  tube,  10.  By  properly  adjusting  the  quantity  of  mercury  the 
tube  or  displacer,  10,  will  cause  the  mercury  to  completely  cover  the 
cone  or  leave  the  tip  bare,  according  as  it  is  raised  or  lowered  in 
the  mercury.  If  the  tip  is  left  bare  a  minute  quantity  of  air  will 
filter  through  the  porous  carbon  and  so  enter  the  light  tube,  but 
once  the  cone  is  covered  with  mercury  again  the  air  is  perfectly 
excluded.  The  only  friction  in  the  operation,  therefore,  is  that  of 
the  glass  tube  in  contact  with  the  liquid  mercury,  which  may  be 
considered  nil.  The  regulation  is  effected  by  connecting  the  dis- 
placer, 10,  to  the  core  of  a  solenoid,  the  solenoid  being  connected 
in  series,  or  in  any  other  effective  way  with  the  current  used  to 
generate  light,  and  so  arranged  that  any  decrease  in  resistance 
will  cause  a  lowering  of  the  mercury  and  a  consequent  laying  bare 
of  i  he  carbon  cone,  thus  admitting  air  to  the  t  iibe  which  will  restore 
again  the  normal  resistance.  The  slight  movement  required  to 
perform  this  regulation  is  the  only  movement  in  the  entire  ap- 
paratus. 

The  only  other  apparatus  required  is  a  small  transformer  to 
produce  a  sufficiently  high  electromotive  force  to  pass  the  current 
through  the  necessary  length  of  tube.  This  may  be  installed  at 
any  convenient  point,  but  is  usually  placed  at  the  ends  of  the 
glass  tubes. 

An  installation  in  an  average  room  consists  of  a  continuous 
glass  tube,  about  the  size  of  one's  wrist  (1%  inches  diameter) 
supported  by  simple  fixtures  on  the  four  walls  or  ceiling  at  about 


[LLUMINA  IIHN 


40  L 


the  height  of  the  picture  molding,  and,  therefore,  out  of  the  direct 
line  of  vision. 

The  alternating  current  from  the  street  mains,  ordinarily 
used  for  incandescent  lamps,  operate.--  this  light,  or  when  direct 
current  is  the  source,  a  motor-generator  is  utilized. 

The  intensity  of  the  light  can  be  regulated  from  a  faint  glow- 
to  20  or  more  candle-power  per  foot,  which  produces  an  extremely 
brilliant  illumination,  yet  with  the  great  advantage  of  low  intrinsic 
intensity,  a  condition  which  is  recognized  as  ideal  by  the  highest 
authorities  on  illumination.  The  eye  suiters  no  inconvenience 
whatever. 

Xo  one  will  contend  that  there  is  any  better  light  under  which 


(i 

r  r-iBe    ' 

SLOWCR) 


fto.  254. 

to  perform  an  operation  than  the  light  of  day.  and  since  the  tube 
really  perfectly  imitates  natural  light,  it  is,  therefore,  the  ideal 
artificial  light,  not  only  so  far  as  diffusion  is  concerned,  but  also 
as  regards  color.  A  wound,  for  example,  will  not  take  on  a  new 
appearance  every  time  as  when  the  brackei  supporting  the  mean 
descent  lamps  is  swung  to  a  new  position,  hut  will  always  preseni 
the  same  shade  to  the  operator.  Further  than  this,  tissues  of  all 
kinds,  blood  clots  and  so  on,  will  have  their  own  perfectly  natural 
daylight  color  values  and  not  be  unnaturally  distorted  as  with 
the  present  forms  of  light.  Furthermore,  the  heal  of  tin  operating 
room  is  not  only  comfortable  to  the  operator,  but  has  a  marked 
effect  also  on  tin1  patient.     When   the  tube  is  used  this   heat   is 


402 


ILLU:.]  I  XA  L'loX 


reduced  80  per  cent;  that  is,  in  direct  ratio  as  the  cost  of  the  elec- 
tric current  is  reduced.  This  saving  is  not  quite  as  great  if  the 
tube  is  required  to  shed  a  white  daylight  color  as  distinguished 
from  a  yellow  sunlight  color. 

Should  this  form  of  light  fulfill  the  expectations  which  may 
reasonably  be  deduced  from  its  present  performance,  the  question 
of  illuminating  will  be  vastly  simplified.  To  use  Mr.  Moore's 
striking  expression,  ''Lighting- will  simply  be  a  matter  of  glass 
plumbing." 

OTHER  POEMS  OF  LIGHTING. 

The  Xeiiist  Lamp  for  illumination  differs  from  all  forms  of 
electric  light  inasmuch  as  it  does  not  depend  upon  a  vacuum. 
This  form  of  light  has  for  its  illuminant  a  glower,  or  a  number  of 


fig.  255. 

these  about  1  inch  long  and  1  -•'!'-!  inch  in  diameter.  These  glowers 
operate  in  the  open  air  and  possess  the  peculiar  property  of  being 
insulators  when  cold  and  conductors  when  hot,  hence  they  must  be 
heated  before  they  will  conduct  electricity  sufficiently  well  to 
maintain  themselves  at  a  light-emitting  temperature. 

The  heating  of  the  glowers  is  accomplished  by  heating  tubes 
made  of  platinum  which  are  heated  by  the  current  of  electricity. 
The  operation  consists  in  the  current  passing  through  the  heater, 
bringing  it  to  a  white  heat:  the  proximity  of  the  glower  to  the 
heater  results  in  the  glower  becoming  a  conductor  (Fig.  255).  A 
cut-out  coil  becomes  energized  by  virtue  of  the  glower  current  pass- 
ing through  it;  an  armature  of  the  cut-out  which  had  heretofore 
closed  the  heater  circuit   is  attracted;    and  this  opens  the  heater 


ILLUMINATION 


40°, 


circuit,  leaving  only  the  glowers  in  operation  until  the  next  time 
that  the  lamp  is  turned  on  (Fig.  256). 

It  is  claimed  for  this  lamp  that  it  has  high  efficiency,  beauti- 
ful quality  of  light,  that  it  is  not  subject  to  pulsation  in  voltage, 
has  an  ideal  distribution  of  light,  and  a  notable  absence  of  shadow 
from  the  lamp  itself.  The  light  must  be  placed  well  above  the  line 
of  vision,  preferably  at  the  ceiling,  so  that  the  Light  is  thrown 
downward. 

There  has  been  devised  a  combination  of  the  Welsbach  and 
Nernst  lamps.  In  it  are  utilized  the  principles  that  the  higher 
the  temperature  of  the  incandescent  body  the  higher  will  be  the 
efficiency,  as  the  visible  part  of  the  spectrum  increases  with  tem- 
perature.    The  invention  consists  in  passing  an  electric  current 

2    Line 


Glower 
fig.  256. 

of  suitable  strength  and  voltage  through  the  incandescenl  body, 
which  is  already  heated  by  the  ordinary  Bunsen  flame,  so  that  the 
body  heated  by  gas  receives  an  additional  rise  of  temperature  by 
the  passing  of  the  electric  current,  whereby  the  production  of 
light  will  be  increased  accordingly. 

As  an  example  of  lighting  sonic  ten  to  twenty  years  ago  the 
following,  taken  from  the  Illuminating  Engineer,  is  of  interesl  : 

When  the  plans  were  formulated  for  the  lighting  installations 
for  'Hie  operating  pavilions  to  be  huilt  for  the  two  public  hospitals 
of  Hamburg,  a  number  of  men  were  chosen  from  the  office  of  the 
[nspector  of  Electric  [Rumination  to  decide  upon  the  method  of 
illumination.     Measurements  of  the  illumination   in  the  old    Pa- 


4"  14 


II  LUMTNATION 


vilion  of  the  Eppendorf  Hospital  made  with  a  Kruss  illuminometer 
showed  an  intensity  of  about  170  meter  candles  at  the  height  of  the 
operating  table  (one  meter  above  the  floor).  This  illumination 
Was  furnished  by  the  use  of  ten  32CP  carbon-    filament    electric 


PIG.    257. OPERATING   PAVILION    IN    THE    EPPENDORF    PUBLIC    HOSPITAL. 

lamps  fitted  with  a  silvered  reflector,  and  placed  at  a  height  of 
2.3  meters,  or  a  distance  of  about  one  meter  above  the  table.  This 
method  of  illumination,  however,  developed  various  disadvantages. 
The  great  amount  of  beat  projected  from  the  reflector  above  their 
beads  was  found  very  annoying  by  the  surgeons;  the  effect  being 
more  and  more  perceptible  as  the  operation  continued.    Another 


ILLUMINATION 


405 


and  greater  disadvantage  was  in  the  intense  shadows  cast,  in  con- 
sequence of  the  light  source  being  concentrated  into  a  single  space, 
which  was  exceedingly  troublesome,  especially  in  the  case  of  post- 
mortems. Besides  this  reflector  arrangement,  tabic  lamps  were 
often  necessary.  From  wide  experience  the  following  require- 
ments were  made  for  the  new  illuminating  apparatus  to  be  pro- 
vided : 


fig.  258.  pig.  259. 

Large    operating      pavilion    in    the    St.  Small  operating  pavilion  in   Si.   G 

George    Public   Hospital.  Public     Hospital. 

First — A  high  intensity  of  illumination. 

Second — The  greatest  possible  degree  of  diffusion. 

Third — A  minimum  radiation  of  heat. 

Fourth — A  perfected  method  of  arranging  the  illuminating 
units  so  as  to  offer  the  least  possible  opportunity  Tor  the  collection 
of  dust. 

Fig.  257  shows  the  new  operating  pavilion  of  the  Eppendorf 


406  ILLUMINATION 

hospital  in  plan  and  elevation.  The  pavilion  is  in  the  front  part  of 
the  genera]  operating  room;  adjoining  it,  and  separated  from  it 
by  a  hand  rail  of  aboul  one  meter  in  height,  is  an  auditorium  of 
amphitheater  form.  As  may  he  seen  from  the  figure,  the  Large  ex- 
tent of  window  servifie  gives  superb  daylight  illumination.  In  ad- 
dition to  this,  the  loom  is  fitted  with  a  skylight,  which  is  furnished 
over  the  operating  pavilion  with  a  ceiling  of  obscured  glass,  as  in- 
dicated by  the  (h-ttcd  line.  AIH'I). 

The  artificial  illumination  is  produced  by  six  15  amp.  direct 
current  arc  lamps.  These  are  suspended  above  the  glass  ceiling 
from  rollers  running  on  slightly  inclined  bars,  so  that  they  can  be 
drawn  into  a  position  above  the  operating  table  by  means  of  wire 
cables  attached  to  them.  Experiments  showed  that  the  best  illum- 
ination was  obtained  when  the  lamps  were  used  open — i.  e.,  without 
glass  shades.  Besides  giving  the  greatest  amount  of  illumination. 
this  arrangement  has  the  advantage  of  preventing  the  shadows 
which  would  be  throwm  upon  the  glass  ceiling  by  the  wire  netting, 
globe-holder  and  glass  globe.  The  lamps  are  ingeniously  arranged 
so  that  the  unavoidable  shadows  of  the  carbon  holders  fall  in  the 
direction  of  the  frame  work  in  the  glass  ceiling.  The  stations  at 
which  measurements  were  made  of  the  illumination  on  a  horizon*: :\\ 
plane  at  about  one  meter  in  height  in  the  space  about  the  operating 
table,  are  indicated  in  the  diagram;  the  corresponding  numbers 
showing  the  illumination  in  meter  candles.  Although  the  intensity 
of  about  {>')  lnx  which  was  secured  in  the  old  operating  pavilion  is 
far  from  being  reached,  the  diffused  illumination  now  obtained 
fully  answers  the  requirements.  Long  experience  shows  that  a 
uniform  illumination  is  far  superior  to  a  considerably  stronger, 
but  less  uniform  intensity. 

The  large  operating  pavilion  of  the  St.  George  Hospital  is 
shown  in  Fig.  258.  In  this  case  the  placing  of  the  light-source  over 
the  glass  skylight  is  impossible  on  account  of  the  construction  of 
the  root',  so  that  the  artificial  illumination  had  to  be  furnished  from 
illuminating  apparatus  within  the  pavilion  itself.  For  this  pur- 
pose three  reflectors  were  used,  one  over  each  of  the  operating 
tables,  and  the  third  in  the  center  of  the  room  to  give  general 
illumination.  The  focus  height  of  the  reflectors  is  four  meters,  so 
that  the  operator  experiences  no  annoyance  from  the  radiation  of 
heat.  Each  reflector  contains  twenty-one  32CP  Osmium  lamps, 
and  in  order  to  give  uniform  distribution  of  light  is  covered  on 
the  hot  torn  with  a  disc  of  frosted  glass.  The  Osmium  lamp  was 
chosen,  not  only  on  account  of  the  saving  in  current,  but  also  on 
account  of  the  -mallei'  radiation  of  heat,  and  the  whiter  light  which 
it  produces.     All  angles,  and  attempts  at  decoration  on  the  re- 


ILLUMINATION 


407 


fleetors,  which  might  collect  dust,  were  avoided.  The  illuminating 
units  are  furthermore  constructed  with  a  regard  to  the  necessity 
of  spraying  the  walls  and  ceiling  of  the  pavilion;  the  requisite 
openings  for  ventilation  suitably  protected  from  the  spraying  be- 
ing provided. 

The  values  of  illumination  given  were  ohtained  at  the  stations 
as  shown  in  Fig.  258,  the  locations  being  along  the  side  walls  of  the 
pavilion  over  the  wash  tables.    The  measurements  were  made  after 
the  pavilion  had  been  fitted  out  with  the  necessarj  apparatus,  -u<  h 
as  operating  tables,  wash  tables,  instrument  cases,  etc.;  the  in- 
stallation having  been  in  use  for  some  time,  the  candle  power  of 
some  of  the  lamps  had  become  reduced.     The  small  pavilion  in 
the  St.  George  Hospital  is  shown  in  Fig.  259.  In  this  case,  also,  the 
ceiling  construction  was  such  that  it  was  necessary  to  place  the 
illuminating  units  within  the  pavilion.    A  reflector  similar  to  the 
one  in  the  old  pavilion  is  placed  3y2  meters  above  the  operating 
table.     For  the  general  illumination,  4  bowls  of  diffusing  glass, 
each  containing  six  32CP  Osmium  lamps,  were  placed  on  the  ceil- 
ing.    The  illumination  obtained  is  shown  in  Fig.  259.     It  will  be 
noted  in  regard  to  the  wiring  that  steel  conduits  were  placed  above 
the  ceiling  with  the  switch  placed  in  the  corridor.     The  requisite 
sockets  and  plugs  Tor  connection  with  hand  lamps  and  surgical 
apparatus  in  the  operating  pavilion  are  placed  in  nickel-plated 
boxes,  the  covers  of  which  are  attached  to  the  wall.     The  walls 
and  ceiling  are  covered  with  white  tiling;   the  doors  are  of  white 
enamel;   the  windows  are  of  obscure  glass,  and  the  floor  covered 
with  shiny  material,  so  that  the  reflection  from  the  walls  and  ceil- 
ing increases  the  illuminating  effect. 

Besides  the  pavilion  of  the  general  operating  rooms  above  de- 
scribed, operating  rooms  are  also  provided  in  the  separate  wards, 
in  which  minor  operations  are  performed.  In  one  of  these,  the 
illumination  of  which  was  provided  in  accordance  with  the  demand 
for  high  intensity,  there  is  much  complaint  on  account  of  the  beat 
radiation  from  the  reflector.  The  illumination  is  provided  by  a 
silvered  reflector  containing  three  25CP  carbon  filament  lamps  at 
about  2.3  meters  above  the  operating  table,  and  a  wall  brackel 
placed  above  the  wash  table.  The  illumination  about  the  operating 
table,  at  a  height  of  about  one  meter  above  the  floor,  is  from  75 
to  125  lux,  and  over  the  wash  table,  35  lux.  These  high  intensities 
are  largely  due  to  the  fact  thai  the  voltage  runs  from  112  to  115, 
instead  of  the  normal,  L08.  Furthermore,  the  reflector  was  aew. 
The  disadvantages  of  the  formation  of  shadows  mentioned  ;it  the 
outset  as  a  result  of  an  illumination  from  a  nearby  source,  were 
very  conspicuous  in  this  case. 


i-i>>  illu.m::<atiox 

HYGIENIC. 

Gas. — Dr.  Beardsley  says,  in  discussing  the  hygienic  effect  of 
gas  Lighting,  that  "In  coming  to  the  question  of  the  effect  of 
combustion  products  of  gas  upon  health,  it  has  sometimes  been 
claimed  that  acetylene  and  carbonic  oxide  were  among  these  prod- 
net-.  Experiments  by  careful  investigators  have  uniformly  failed 
to  show  the  presence  of  acetylene.  In  regard  to  carbonic  oxide, 
some  experimenters  have  been  unable  to  find  any,  while  others 
claim  to  have  detected  traces.  The  insignificant  amount  of  the 
latter  is  shown  by  the  following  calculation:  In  a  room  12  ft. 
wide.  16  ft.  long,  10  ft.  high,  having  three  changes  of  air  per  hour 
and  lighted  by  a  gas  jet  burning  6  en.  ft.  per  hour,  the  quantity 
of  carbonic  oxide  has  been  claimed  would  amount  to  about  1  part 
in  o,OOn.OOi).  As  the  amount  required  to  produce  symptoms  of 
poisoning,  even  after  several  hours  of  exposure,  is  1,500  parts  in 
3,000,000,  the  matter  cannot  be  considered  of  importance.  Sul- 
phur dioxide  in  almost  infinitesimal  quantities  is  also  produced 
by  a  gas  burner. 

A  cubic  foot  of  gas  requires  for  its  combustion  the  oxygen 
contained  in  6.02  en.  1't.  of  air,  and  forms  in  burning  .82  en.  ft.  of 
carbonic 'acid  and  1.15  en.  ft.  of  water  vapor.  A  fiat  flame  gas 
burner  consumes  aboul  0  en.  ft,  an  hour.  A  AYelsbach  burner 
gives  about  three  times  the  light  with  a  consumption  of  3.5  cu.  ft. 
per  hour,  a  little  more  than  half  that  required  for  a  fiat  flame. 

Regarding  the  amount  of  carbonic  acid  in  the  human  breath, 
probably  the  most  accurate  figures  are  those  obtained  in  the  res- 
piration calorimeter  experiments,  conducted  at  Micldietown.  Conn. 
From  these  experiments  it  was  found  that  the  amount  of  carbonic 
acid  exhaled  varies  greatly,  according  to  the  amount  of  work  a 
man  is  doing.  A  man  sleeping  produces  about  .48  en.  ft.  per  hour, 
one  exercising  moderately  about  4  en.  ft.  In  the  ordinary  living 
rooms  a  man  seated  will  exhale  aboul  .70  cu.  ft.  of  carbonic  acid 
per  hour.  In  addition  organic  matter  of  had  odor  is  also  evolved 
both   by   lungs  and  skin. 

It  is  t<>  he  noted  that  the  carbonic  acid  produced  by  burning 
gas  is  accompanied  only  by  water  vapor  and  some  insignificant 
amounts  of  sulphur  compounds.  The  carbonic  acid  from  human 
beings,  however,  is  accompanied  both  by  water  vapor  and  organic 
impurities  from  the  lungs  and  skin.  This  is  an  important  fact, 
because,  startling  a-  it  may  sound,  carbonic  acid  itself  has  no 
poisonous  or  injurious  effect  on  the  system.  Regulations  as  to 
the  amount  of  carbonic  acid  permissible  in  the  air  of  a  room  are 
made  hem  use  it  is  found  that  the  organic  impurities  and  the  car- 
bonic acid  given  off  from  the  body  bear  a  regular  proportion  to 


ILLUMINATION  4< )!  I 

each  other.  It  is  difficult  to  directly  determine  the  amount  of 
organic  impurities  present,  but  if  the  amount  of  carbonic  acid  is 
learned,  the  organic  impurities  are  known  by  inference.  The 
statement  that  carbonic  acid  itself  is  not  at  all  harmful  is,  of 
course,  contrary  to  the  older  belief,  but  it  is  the  conclusion  of  the 
best  investigators. 

It  appears  that  we  may  not  attribute  a  sensation  of  close  or 
bad  air  in  a  room  to  an  excess  of  carbonic  acid.  Authorities  tell 
us  also  that  any  ordinary  diminution  of  the  per  cent,  of  oxygen 
present  cannot  account  for  it.  The  cause  seems  to  be  something 
quite  different.  Investigators  lay  it  to  three  factors.  The  first, 
though  not  the  most  important,  is  unpleasant  odors.  The  effect  of 
these  is  mental  rather  than  physical,  but  very  real  nevertheless 
But  the  two  most  important  causes  of  closeness  arc  high  tempera- 
ture and  excessive  moisture,  particularly  the  latter.  Tempera- 
ture and  moisture  are  related  to  each  other  in  the  fact  that  with 
a  high  temperature  more  moisture  is  allowable  and  necessary  than 
with  a  low  temperature.  A  certain  balance  between  the  two,  or  a 
per  cent,  of  saturation,  is  necessary  for  health  and  comfort.  The 
removal  of  moisture  from  the  body  by  insensible  perspiration  and 
by  the  breath  will  be  unduly  hastened  or  hindered,  as  the  case 
may  be,  according  as  there  is  a  lack  or  an  excess  of  moisture  in 
the  air.  An  excess  of  moisture,  however,  appears  to  be  most  often 
responsible  for  discomfort. 

Since  water  vapor  is  one  of  the  products  of  the  combustion  of 
gas,  we  are  at  once  met  by  the  question:  What  is  the  effect  of 
gas  lights  upon  the  moisture  in  a  room.'  A  certain  amounl  of 
water  vapor,  as  said,  is  necessary  for  health  and  comfort.  Au- 
thorities say  about  50  per  cent,  of  that  required  to  produce  satura- 
tion of  the  air  is  the  proper  amount.  It  is  only  in  the  summer  time 
that  the  air  of  our  houses  as  drawn  in  from  outside,  contains  thai 
amount.  As  soon  as  fall  comes  and  the  furnaces  are  started,  there 
is  the  usual  complaint  of  the  excessive  dryness  of  our  rooms,  and 
water  is  often  purposely  evaporated  to  supply  the  lack.  It  is 
only  in  the  summer,  therefore,  that  the  moisture  from  the  gas 
flame  would  be  undesirable,  and  in  the  summer  time  our  houses 
are  as  open  as  it  is  possible  to  make  them.  With  air  pouring  in 
through  every  door  and  window,  the  moisture  added  to  the  air  by 
a  gas  flame  is  indistinguishable.  During  the  rest  of  the  year  I  he 
addition  of  moisture  by  gas  is  not  only  not  an  annoyance,  but  a 
benefit. 

It  may  be  said  that  it  is  anything  but  the  object  of  the  writers 
to  undervalue  the  importance  of  good  ventilation.  Thai  is  a  mat- 
ter of  which  experience  has  shown  the  necessity,  irrespective  of  the 


410  1LLUMIXAT10N 

question  of  lighting.  It  does  appear,  however,  that  efforts  to 
show  the  poisonous  character  of  the  products  of  the  combustion  of 
gas  lack  corroboration  by  the  best  scientific  investigations. 

Jt  is  claimed  for  acetylene  that  its  vitiating  effects  are  only 
about  one-eighth  those  of  coal  gas,  and  that  its  heating  property 
is  very  slight. 

The  hygienic  effects  of  electrical  lighting  need  no  special  men- 
tion. There  are  no  odors,  and  no  carbon  dioxide  or  other  gases 
in  this  form  of  lighting.  The  heating  effect  of  such  lighting  in  all 
its  forms  is  of  no  consequence  so  far  as  hygienic  effects  are  con- 
cerned,  for  this  is  the  dry  heat  of  radiating  surfaces  and  not  the 
direct  heat  of  combustion. 


CHAPTER  XXIII. 

REFRIGERATION. 

There  are  two  processes  of  obtaining  refrigeration — natural 
and  artificial.  In  the  former  the  necessary  cold  is  produced  by 
melting  ice,  while  the  latter  is  produced  mechanically.  The  nat- 
ural method  need  only  be  mentioned  as  a  process  without  special 
apparatus. 

The  ordinary  ice  box  or  refrigerator  is  familiar  to  every  (me. 
In  hospitals  it  is  usually  necessary  to  have  special  boxes  built, 
depending  wholly  upon  the  size  of  the  institution.  The  building 
of  such  boxes  follows  the  same  rules  as  those  for  artificial  refriger- 
ation—the only  difference  in  the  boxes  or  rooms  being  in  the 
method  of  obtaining  low  temperatures.  In  either  process  a  gen- 
eral refrigerator  large  enough  to  take  care  of  the  supplies  lor  the 
hospital  is  ordinarily  put  somewhere  in  proximity  to  the  kitchen 
department.  In  the  diet  kitchens  there  are  placed  small  boxes  to 
take  care  of  local  supplies.  In  cases  where  cold  storage  is  re- 
quired, special  rooms  are  built  for  this  purpose. 

The  essential  in  either  system  is  the  same-  namely,  that  re- 
frigeration is  the  withdrawal  of  heat.  Whether  this  be  done  by 
the  melting  of  ice,  as  in  the  natural  process,  or  by  one  of  the 
methods  of  artificial  refrigeration,   the  process   is   primarily  the 

same. 

Natural  ice  for  hospitals  has  long  heen  condemned  as  an 
agent  for  preserving  foods  any  length  of  time.  The  time  has 
passed  for  attempting  to  hold  foods  by  means  of  ice.  as  it  is  im- 
possible to  maintain  a  sufficiently  low  temperature  and  dry  at- 
mosphere to  do  the  work.  Different  classes  of  foods  require  dif- 
ferent temperatures,  which  cannot  he  secured  by  the  use  of  ice; 
but  by  mechanical   refrigeration  temperatures  may   ho  perfectly 

controlled. 

The  advantages  of  mechanical  refrigeration  arc  daily  becom- 
ing better  known  and  appreciated,  and  il  has  become  indispensable 
to  a  great  variety  of  industries  as  well  as  to  every  household.  It 
makes  possible  the  preservation  of  food  products,  supplb »s  pure, 
hygienic  ice  at  all  times,  and  forever  does  away  with  the  Lodg- 
ment of  poisonous  germs  which  accumulate  in  wood  or  metal  lined 


41 2  KEFEIGEBATION 

refrigerators  that  become  water  soaked  and  soggy  from  melting 
ice. 

Dr.  Ross  says:  "The  two  questions  of  most  interest  to  institu- 
tions are  the  manufacture  of  ice  and  the  storing  of  food.  To  de- 
termine whether  it  is  advantageous  to  manufacture  ice,  many 
questions  must  be  taken  into  consideration.  If  the  supply  of  water 
from  which  natural  ice  is  frozen  is  had,  or  the  facilities  for  ob- 
taining it  difficult — such  as  exists  in  our  more  southern  cities — - 
it  is  probable  that  a  much  more  wholesome  and  cheaper  product 
can  be  obtained  by  artificial  refrigeration.  In  a  table  published  in 
a  recent  book  on  artificial  refrigeration,  after  making  a  proper 
allowance  for  engineers.  Laborers,  coal  helpers,  oil,  operating  ex- 
penses and  sundries,  it  has  been  determined  that  with  a  machine 
which  will  make  one  ton  per  day  the  ice  will  cost  $4.25  per  ton; 
with  a  two-ton  machine,  $2.50  per  ton;  with  a  four-ton  machine, 
$1.88  per  ton;  a  six-ton  machine,  $1.51  a  ton;  a  ten-ton  machine, 
$1.37;  with  a  one-hundred-ton  machine,  *0.62.  These  figures  must 
necessarily  vary  with  the  cost  of  fuel,  labor,  etc.  Coal  on  the 
above  estimate  has  been  figured  at  $3.00  per  ton,  and  the  engineer- 
ing heli i  as  having  no  other  duties.  In  a  small  plant  the  expenses 
of  engineering  could  probably  be  eliminated,  as  this  work  could 
be  combined  with  other  duties  without  increasing  the  cost. 

Some  of  our  large  cities,  in  the  neighborhood  of  which  it  is 
difficult  to  obtain  pure  water  supply  and  pure  ice,  are  placing 
such  restrictions  about  the  ice  business  as  will  have  a  tendency  to 
make  the  manufactured  article  more  popular.  Natural  ice,  from 
a  certain  source,  may  at  the  beginning  of  a  winter  season  be  pure, 
so  far  as  analysis  can  show,  but  later  in  the  season,  when  the 
frozen  earth  prevents  tilt  rat  ion,  the  surface  water  readily  finds 
it-  way  to  the  larger  body  of  water,  there  forms  into  ice,  and 
shows  every  evidence  of  contamination. 

One  of  the  ordinances  of  Chicago  requires  that  all  ice  to  be 
delivered  within  the  city  for  domestic  use  shall  be  pure  and  health- 
ful. Healthful  ice  is  defined  as  "ice  which  upon  chemical  and 
bacteriological  examination  shall  be  found  to  he  free  from 
nitrates  and  pathogenic  bacteria,  and  to  contain  not  more  than 
9-1000  of  one  pari  of  free  ammonia  and  9-100U  of  one  part  of 
albuminoid  ammonia  in  L00,000  parts  of  water.  Water  for  ice 
should  be  prepared  as  stated  below. 

For  the  preservation  of  perishable  goods,  the  temperature  is 
the  chief  factor,  but  other  conditions,  such  as  clean,  dry,  well- 
ventilated  rooms  and  pure  air,  are  at  times  almost  of  equal  im- 
portance. Humidity  is  of  almost  ;<s  much  importance  as  tem- 
perature at  times.     Extreme   cold  temperature  will  affect  certain 


REFRIGERATION  413 

articles  in  such  a  way  that  ay  hen  removed  from  cold  storage  they 
quickly  deteriorate.  The  methods  by  which  articles  pass  from 
cold  storage  to  the  consumer  are  of  such  importance  that  the  qual- 
ity of  the  article  is  greatly  influenced  by  them.  A  cold  storage 
room  should  not  be  too  dry,  for  if  so.  it  will  favor  the  drying  out 
of  the  goods  and  their  shrinkage.  If  the  moisture  is  kept  below 
the  point  of  saturation  the  best  results  are  obtained.  Proper  ven- 
tilation will  safely  regulate  these  conditions.  A  good  method  is 
to  force  the  air  over  the  cooling  pipes  into  the  cooling  room;  the 
air  should  always  be  admitted  at  the  top  of  the  room. 

Meat  rooms  and  rooms  used  for  the  storage  of  other  articles 
of  diet  should  be  periodically  cleaned  and  disinfected;  formalde- 
hyde gas  is  easily  applied  and  very  efficacious." 

Mechanical  Kefrigeration. — There  'are  two  ammonia  sys- 
tems now  in  use,  the  absorption  and  the  compression  systems.  It 
is  very  generally  conceded  that  the  compression  system  for  prac- 
tical purposes  is  by  far  the  better.  The  medium  used  as  the  re- 
frigerant is  anhydrous  ammonia.  There  are  other  systems  using 
other  refrigerants  than  ammonia,  such  as  carbon  dioxide,  sulphur 
dioxide  and  air,  but  there  are  really  so  few  machines  of  this  type 
in  actual  operation  that  they  are  hardly  to  be  considered. 

Anhydrous  ammonia  boils  at  about  2Sy2  degrees  below  zero 
F.  when  under  atmospheric  pressure.  At  temperatures  below  this 
it  is  a  liquid,  while  at  temperatures  above — and  this  includes  the 
ordinary  range  of  storage  temperatures — it  is  a  gas.  It  is  this 
low  boiling  point  that  makes  it  a  good  refrigerating  agent.  When 
allowed  to  evaporate  it  takes  up  heat  in  the  process.  Every  pound 
of  ammonia  during  evaporation  is  capable  of  taking  up  a  cert;' in 
quantity  of  heat.  Were  it  not  for  the  expense  for  ammonia,  the 
compressor  might  be  done  away  with  and  the  ammonia  after 
evaporation  allowed  to  escape  into  the  atmosphere.  To  recon- 
vert the  gas  to  a  liquid  and  remove  the  heat  which  has  been  ab- 
sorbed in  the  evaporation  is  the  function  of  the  refrigerating  ma 
chine. 

There  are  three  processes  necessary  in  the  compression  sys 
tern  of  refrigeration — namely,  compression,  condensation  and  e.\ 
pansion  of  the  cold-producing  agent,  which  three  form  a  continu- 
ous cycle.     These  processes  are  accomplished  by  machinery  and 
appliances  especially  adapted  to  each.    The  compressor  is  simply  a 
pump  specially  designed  for  the  purpose  of  compressing  the  am 
monia  gas  and  forcing  it  into  the  condenser  under  pressure.    The 
condenser  is  a  series  of  continuous  pipes  confining  the  gas  under 
pressure  while  subjected  externally  to  a  constant  (low  of  cold  water. 
The  expansion  coils  are  continuous  coils  of  pipe  into   which  the 


j  j  J  REFRIGERATION 

liquid  ammonia  is  allowed  to  expand  through  a  small  orifice  in  the 
expansion  valve.  This  li.|iii<i  expands  about  1,500  times  its  volume, 
and  in  so  doing  absorbs  heat  from  the  surrounding  atmosphere 
or  brine,  as  the  case  may  be,  thus  producing  intense  cold.  The 
expansion  coils  are  connected  to  the  suction  pipe  leading  back  to 
the  compressor,  and  thus  the  gas  returns  to  renew  its  cycle. 

From  the  above  it  will  be  seen  that  the  heat  absorbed  by  the 
ammonia  is  in  turn  absorbed  by  the  cold  water  circulating  around 
the  compressor  cylinder  and  through  the  condenser.  The  am- 
monia, then,  is  simply  the  agent  by  means  of  which  a  compara- 
tively high  temperature  in  the  water  produces  a  low  temperature 
in  the  rooms  or  boxes  to  be  cooled. 

The  ammonia  is  not  used  up  in  the  process  of  refrigeration, 
but  travels  from  the  condenser  and  compressor  to  the  expansion 
coils  and  is  then  pumped  back,  in  a  continuous  cycle.  The  ex- 
pense for  ammonia  is  limited  to  that  which  escapes  from  the  sys- 
tem through  leakage  and  will  depend  upon  the  care  ami  attention 
given  by  the  operator. 

There  are  three  practical  methods  of  producing  temperatures 
desired  in  cooling  rooms,  boxes  or  tanks  in  the  compression  sys- 
tem— namely,  direct  expansion,  brine  circulating,  and  air  circu- 
lating systems. 

Direct  Expansion. — In  this  system  the  liquid  ammonia  is  al- 
lowed to  expand  in  pipes  placed  in  the  rooms  to  be  cooled  and  in 
process  of  expansion  absorbs  the  heat  in  the  rooms  to  be  cooled. 
Brine  Circulating. — Instead  of  being  placed  directly  in  the 
rooms  to  be  cooled  the  expansion  coils  are  placed  in  an  insulated 
tank  of  brine.  The  expansion  lowers  the  temperature  of  the  brine, 
which,  of  course,  remains  in  a  liquid  form  at  temperatures  far 
below  the  freezing  point  of  pure  water.  This  cold  brine  is  then 
pumped  through  pipe  coils  in  the  rooms  to  be  cooled,  and  returns 
to  the  tank  to  be  used  again. 

Air  Circulating.  In  this  method  expansion  coils  are  placed 
in  an  insulated  box,  or  room,  through  which  the  air  is  drawn  to  be 
cooled  by  passing  over  coils  and  distributed  to  the  cooling  rooms, 
returning  thence  through  ducts  70  the  pipe  room  to  begin  the  cir- 
cuit again. 

The  three  system.-  of  refrigeration — the  direel  expansion,  the 
brine  and  the  air  circulating  are  each  especially  adapted  to  cer- 
ium uses.  The  direct  expansion  is  more  largely  used  than  the 
others,  as  it  is  installed  at  less  expense,  and  lower  temperatures 
can  be  obtained. 

The  brine  system,  although  more  expensive,  is  often  more 
advantageous  under  certain  conditions.     For  instance,  where  it  is 


EEFRIGER  AT  I  <  I X  41  5 

desired  to  run  the  compressor  only  a  part  <>i  the  day,  the  !>rine 
pump  is  kept  running,  thus  circulating  the  cooling  fluid.  Also 
where  there  are  many  small  rooms  or  boxes  to  be  cooled  it  is  diffi- 
cult to  control  the  temperatures  with  the  small  amount  ol'  piping 
in  each  room  and  a  separate  expansion  valve,  but  with  the  con- 
stant circulation  of  the  brine  the  temperatures  are  perfectly  regu- 
lated. 

The  air  system  is  used  in  comparatively  lew  plants  at  the 
present  time.  In  using  this  system  it  is  necessary  to  run  con- 
tinuously. It  is  not  well  adapted  where  a  very  low  temperature 
is  required,  but  an  even  temperature  and  dry  atmosphere  can  be 
successfully  maintained. 

Capacity. — Refrigerating  capacity  is  measured  in  the  cooling 
effect  of  melting  one  ton  of  ice.  A  ten-ton  refrigerating  machine, 
when  operated  twenty-four  hours  daily,  does  the  same  amount  of 
cooling  as  would  be  produced  by  melting  ten  tons  of  ice.  In  select- 
ing the  size  of  machine  required  for  any  plant,  it  is  necessary  to 
get  one  large  enough  to  do  the  work  when  the  maximum  cooling  is 
demanded.  For  this  reason  it  is  best  to  have  a  machine  much 
larger  than  the  average  consumption  of  ice.  For  cold  storage 
purposes,  or  for  work  where  the  demand  upon  the  machine  is 
constant  during  the  entire  twenty-four  hours,  a  three-ton  machine 
will  take  the  place  of  three  tons  of  ice.  But  if  three  tons  of  ice 
are  needed  in  six  hours,  it  would  require  a  machine  four  times  as 
large,  or  twelve  tons. 

It  is,  of  course,  possible  to  store  up  a  part  or  all  of  the  cooling 
energy  of  the  plant  for  use  when  required. 

There  are  refrigerator  boxes  arranged  to  permit  the  machine 
to  be  operated  only  a  part  of  the  time  and  still  maintain  a  uniform 
temperature  in  the  boxes,  as  shown  in  ill  astral  ion  (  Pig.  264). 

The  question  naturally  arises  what  is  the  cost  of  mechanical 
refrigeration:'  The  operating  cost  is  practically  just  that  of  the 
power  required  to  run  the  compressor,  and  this  is  very  slight. 
The  machine  is  generallv  run  only  when  the  rest  of  the  machinery 
is  operated,  and,  therefore,  requires  very  little  additional  time  or 
attention. 

Ice  Making. — Of  the  many  systems  that  have  been  devised 
for  the  manufacture  of  artificial  ice,  there  are  hut  two  now  in 
practical  use:  First,  the  can  system.  Second,  the  plate  system. 
The  can  system  is  the  one  most  extensively  used,  the  Lee  being 
produced  in  galvanized  iron  cans  immersed  in  salt  brine,  kept  at 
a  temperature  far  below  the  freezing  point  of  water  by  the  evap- 
orating properties  of  ammonia,  through  coils  submerged  in  ih<' 
brine. 


£15  REFRIGERATION 

Evaporating  coils  in  the  smaller  sizes  are  usually  made  in 
oval  form  of  continuous  pipe,  having  no  joints  except  where  con- 
nected to  headers  at  top  and  bottom.  Liquid  ammonia  is  admit- 
ted to  the  upper  header  by  an  expansion  valve,  and  evaporates 
from  this  bath  of  liquor,  into  the  several  coils.  The  lower  header, 
•  ailed  the  gas  header,  is  in  connection  with  the  suction  side  of  the 
compressor,  and  hence  serves  to  assemble  the  gas  for  transmission 
to  the  machine,  licit-  it  is  Gompressed,  sent  to  the  condenser, 
liquefied  and  deposited  in  the  receiver  ready  for  use  again.  The 
coils  are  contained  in  an  iron  or  wooden  tank,  well  insulated.  The 
galvanized  iron  cans,  which  contain  the  water  to  be  frozen,  as  be- 
fore mentioned,  are  immersed  in  the  brine,  and  a  coating  of  ice 
soon  forms  on  the  inside,  and  after  a  lapse  of  time,  according  to 
the  size  of  the  cans,  solid  blocks  of  ice  are  produced. 

Transparent  ice  is  obtainable  by  a  complicated  process  of  dis- 
tilling the  water  by  passing  steam  through  a  condenser,  skimming 
off  the  impurities,  reboiling  the  water,  cooling  it,  and  then  putting 
it  into  the  cans — then  freezing  it  for  a  period  of  48  to  60  hours. 

The  same  machine  is  used  to  produce  ice  that  is  used  for  re- 
frigerating purposes,  but  it  must  be  borne  in  mind  that  a  live-ton 
refrigerating  machine  will  not  produce  five  tons  of  ice.  Refriger- 
ating machines  are  rated  in  tons  refrigerating  capacity,  and  by 
a  ton  is  meant,  as  stated,  the  cooling  effect  equivalent  to  the  melt- 
ing  of  a  ton  of  ice  in  twenty-four  hours. 

The  ice-making  capacity  is  less  than  the  refrigerating  ca- 
pacity, because  of  the  fact  that  the  water  must  be  cooled  from  its 
initial  temperature  to  32  degrees  F.  before  freezing  starts.  In 
addition  to  this  the  freezing  tank  must  be  refrigerated,  which 
requires  refrigeration  equal  to  cooling  a  box  of  that  size  to  32 
degrees.  In  consequence  the  ice-making  capacity  is  from  one-half 
to  two-thirds  the  refrigerating  capacity. 

I  xsulation. — The  proper  insulation  of  buildings  for  cold  stor- 
age i>  a  matter  of  greatest  importance  if  ultimate  economy  i>  to 
be  considered.  Without  good  and  heavy  insulation  greatly  in- 
creased refrigerating  power  must  be  used.  It  may  be  possible  to 
produce  and  maintain  low  temperatures  in  poorly  insulated  rooms, 
but  in  all  cases  it  is  done  at  the  expense  of  extra  fuel.  Hence  we 
see  that  insulation  is  a  vital  point  in  refrigeration  and  careful 
study  should  be  given  both  to  the  materials  used  and  to  the  meth- 
od of  constructing  walls.  If  it  were  possible  to  construct  a  per- 
fectly insulated  room  for  cold  storage,  the  refrigerating  machine 
would  have  but  little  to  do  after  the  temperatures  were  once  pro- 
duced, except  to  abstract  the  heat  from  foods  when  they  were 
first  put  into  the  rooms. 


REFRIGERATION 


417 


I— I 
P 

to 

Ci 

o 


i  I  s 


REFRIGERATION 


No  definite  rules  can  be  given  for  proper  insulation  in  the 
construction  of  buildings  or  boxes,  as  conditions  are  so  varied, 
but  in  any  case  solid  walls,  especially  of  brick  or  stone,  must  be 
avoided.  Solid  walls  or  partitions  are  continuous  conductors  of 
iieat  and  moisture.  Many  times  architects  have  built  solid  walls 
instead  of  walls  having  air  spaces,  and  then  wondered  whv  frost 
or  dampness  should  appear  on  the  inside  of  the  building.     Dead 


fig.  261. 
air  spaces,  filled  spaces,  tongued  and  grooved  boards  and  insulat- 
ing paper  are  essential  to  satisfactory  insulation.  Care  should  be 
taken  in  selecting  the  paper  for  insulating  purposes.  Porous, 
spongy  paper  will  not  do  the  work.  Choose  a  well-known  brand, 
manufactured  by  a  responsible  firm.  The  paper  should  be  durable, 
water-proof,  vermin-proof,  non-combustible  and  odorless.  Care 
must  be  taken  to  make  all  openings,  such  as  doors  and  windows, 


fig.  262. 
as  nearly  airtight  as  possible.    The  doors  should  be  light  and  with 
the  edges  lifted  to  overlap  the  jambs.     Windows  should  be  few, 
hut,  where   necessary,  made  triple  glazed.     For  entrance  to   all 
rooms  an  anteroom  should  be  provided,  if  possible. 

Fig.  260  shows  in  detail  various  methods  of  insulation.     Some 
show  how  to  adapt  insulation  to  old  walls  of  brick,  stone  or  wood; 


REFEIGKRATION 


419 


others  how  to  construct  new  walls.  Some  show  methods  of 
construction  that  might  be  used  when  initial  expense  must  be 
considered  in  spite  of  subsequent  losses. 

Kefrigerator  Piping.— The  illustrations  show  five  methods 
of  piping  refrigerator  boxes.  In  cases  where  a  uniform  low  tem- 
perature is  desired  and  the  machine  is  not  to  be  operated  twenty- 
four  hours  per  day,  Figs.  261,  -62  for  direct  expansion  and  Fig. 
26o  for  brine  circulation  is  advised.    Fig.  261  is  similar  to  Fig.  264, 


fig.  263. 

except  that  a  rectangular  tank,  holding  several  hundred  pounds 
of  brine,  is  placed  on  the  side  of  the  room.  The  ammonia  circu- 
lates through  the  exposed  coils  first  and  then  through  the  coils 
submerged  in  the  brine.  At  the  end  of  each  daily  run  the  brine  is 
cooled  down  to  zero  or  a  little  above,  thus  storing  sufficient  cold 


fig.  264. 

to  maintain  a  low  temperature  while  the  machine  is  shul  down. 
The  success  of  this  system  depends  upon  (lie  thorough  insulation 
of  the  refrigerator  Avails. 

In  Fig.  262  the  coils  and  tank  arc  placed  in  a  loft,  the  air  cir- 
culating up  a  flue  at  the  left,  then  across  the  brine  tank  through  the 


42i  I 


REFRIGERATION 


coils  and  down  again  to  the  room  through  a  tlue  at  the  right.    This 
gives  a  very  dry  atmosphere  as  well  as  low  temperature. 

Where  ice  is  to  be  made  the  plant  should  preferably  be  run 
twenty-four  hours,  in  which  case  the  room  for  storage  is  equipped 
as  shown  in  Fig.  265. 

Fig.  263  consists  of  coils  and  closed  brine  tank  through  which 
cold  brine  is  circulated.  The  compressor,  brine  tank  and  all  am- 
monia piping  are  compactly  located  in  the  basement,  and  the 
refrigerators  are  on  the  upper  floors.  The  machine  needs  to  be 
operated  but  from  five  to  fourteen  bonis  daily,  depending  on  con 
dit ions,  and  there  is  no  ammonia  piping  in  the  boxes. 

The  table  given  herewith  is  for  approved  cold  storage  tem- 
peratures, and  will  be  useful  in  computing  the  temperatures  re- 
quired in  any  given  space  or  in  the  whole  box. 


fig.  265. 

Deg. 
Fahr 

Beef 36 

Hogs ....29 

Lamb  and   Mutton    32 

Veal   34 

Meats,  in  pickle  or  brine   35 

Butter  (must  be  kepi  separate  from  other  goods). ...32 

Eggs  (must  be  turned  occasionally) •*'>-' 

Cheese   32 

Lard  38 

Poultry,  to  freeze 5 

Poultry,  when   frozen    25 

Game,  to   freeze    ° 

( i.iine,  when  frozen    25 

Fish   25 

( Jvsters    °3 


to 


40 

32 

36 

3(5 
tO 
38 
34 
34 
40 
10 
28 
10 
28 
28 
45 


REFRIGERATION*  42l 

Beer  33  l'  42 

Wines 40  "  45 

Cider   30  "  40 

Fruits 33  -  ■  36 

Vegetables 34  '  40 

Canned  Goods   38  "  40 

Flour  and  Meal 40 

fig.  266. 


CHAPTER  XXIV. 

EQUIPMENT  IN  CONSTRUCTION. 

Such  equipments  as  are  described  in  this  section  are  con- 
junctive features  of  the  hospital  and  must  be  provided  for  and 
built  in  as  the  building  progresses.  They  consist  of  elevators,  dumb 
waiters,  vacuum  cleaning  systems  and  sterilizers.  Shades  and 
ranges  arc  also  included,  as  these  require  special  attention. 

Elevators. — There  is  no  standard  that  can  be  established  for 
the  elevators  in  hospitals,  as  their  pattern,  the  motive  power, 
their  location  and  their  general  use  would  all  be  factors  in  deter- 
mining tli  is. 

Elevators  in  hospitals  are  divided  into  two  classes,  however, 
as  they  are  in  other  buildings — namely,  passenger  elevators  and 
what  are  virtually  freight  elevators,  and  which  are  for  the  use  of 
patients  when  on  the  wheel  chair  or  wheel  stretchers.  The  only 
difference  in  these  elevators  is  their  size  and  their  general  equip- 
ment or  difference  in  the  cage. 

All  hospitals  are  not  necessarily  equipped  with  two  elevators, 
as  one  large  one  is  sufficient  for  the  needs  of  institutions  contain- 
ing up  to  ion  or  L50  be<!s.  Beyond  this  limit  it  is  somewhat  in- 
convenient to  use  one  elevator  for  patients  and  other  passengers, 
and  for  the  conveying  of  heavy  supplies  and  linens.  In  such  insti- 
tutions the  dumb  waiters  are  not  usually  made  sufficiently  large 
or  their  machines  of  such  power  (often  being  operated  by  hand) 
to  carry  such  articles  as  Hour  iu  barrel  lots,  nor  can  the  cuiuber- 
some  baskets  of  linen  be  conveyed  in  such  dumb  waiters.  The 
wheel  stretchers  occupy  so  much  space  on  an  elevator,  and  in  gen- 
eral hospitals  it  is  necessary  to  take  patients  up  and  down  so  con- 
tinuously for  one  reason  or  another,  that  when  the  limit  of  ca- 
pacity is  reached  it  is  advisable  to  install  two  elevators — the  small- 
er one  for  passengers  and  the  larger  one  for  stretchers  and  sup- 
plies. There  is  a  decided  advantage  in  this,  because  the  larger 
elevator  can  be  located  so  that  it  will  serve  both  the  operating 
and  dressing  department  ami  also  the  store  rooms  and  refrigera- 
tors for  the  kitchen  department,  without  interfering  in  the  least 
with  the  rest  of  the  hospital;  in  other  words,  it  can  be  more 
readily  isolated  so  as  to  cause  no  disturbance,  and  still  be  handy 
enough  to  be  accessible  from  all  parts  of  the  hospital.    This  then 


EQUIPMENT   IN   CONSTBTJCTION  423 

leaves  the  passenger  elevator  for  passengers  only,  and  makes  it 
necessary  to  nse  only  suck  power  as  would  be  devoted  to  this  con- 
tinuous service,  leaving  the  other  elevator  for  the  intermittent  and 
heavier  service. 

Elevators  are  of  several  kinds  and  the  type  which  is  to  be 
installed  depends  wholly  upon  the  power  available  and  the  general 
conditions  existing. 

They  may  be  classified  as  follows:  Those  operated  by  en- 
gines, either  steam,  gas,  gasoline  or  electric,  in  which  there  is  a 
drum  at  the  machine  placed  in  the  basement,  and  the  lifting  cable 
runs  up  and  over  an  overhead  sheave  or  wheel  and  down  to  the 
drum;  the  direct  lift  elevator,  in  which  the  machine  and  drum 
are  put  directly  over  the  elevator,  usually  in  a  pent  house,  this 
being  applicable  only  to  electric  hoists;  the  hydraulic  elevator, 
which  is  operated  by  a  cylinder  of  proper  length  into  which  water 
is  pumped;  and  the  direct  lift  or  plunger  type  of  hydraulic  ele- 
vator, which  is  operated  by  a  piston,  lifting  directly  under  the 
elevator.  There  are  also  hand  types  operated  by  hand  power  by 
means  of  rope  and  wheel  gearing. 

All  elevators  have  either  hand  or  automatic  control.  Of  the 
former  there  are  the  rope  control  and  lever  control,  the  latter  be- 
ing of  two  types  in  electric  elevators — namely,  the  full  lever  and 
the  magnet  control.  The  automatic  elevator  is  controlled  by  push 
button  devices.  This  is  known  as  the  full  automatic  push  button 
control  elevator,  and  is  especially  designed  for  hospitals  where 
no  regular  elevator  operator  is  employed.  The  control  of  this 
elevator  is  interesting  in  view  of  the  fact  that  it  requires  no 
operator.  There  is  a  push  button  at  each  landing.  Pressing  one 
of  these  buttons  calls  the  car  to  that  landing,  where  it  stops  auto- 
matically. On  entering  the  car,  the  passenger  finds  a  scries  of 
push  buttons  (one  lor  each  floor)  and  has  only  to  press  the  one 
desired.  The  car  then  proceeds  to  th.it  floor,  where  ii  stops  auto- 
matically. While  the  car  is  running  or  while  any  shafl  dooi  is 
open,  no  one  can  interfere  with  its  operation.  Safety  locks  keep 
the  doors  locked  except  when  the  car  is  at  the  landing.  Safety 
switches  prevent  the  elevator  from  being  started  unless  all  doors 
are  closed. 

All  elevators  should  be  equipped  with  starting  and  stopping 
devices  which  give  perfect  control  of  the  car.  In  these  the  speed 
of  cutting  out  resistance  should  be  entirely  regulated  at  the  ma- 
chine; the  lever  on  the  car  in  these  can  be  instantly  reversed 
without  causing  the  slightest  damage,  and  are  so  arranged  that 
when  the  operator  removes  his  hand  from  the  lever  it  will  return 
to  a  central  position,  stopping  the  car  in  the  usual  way.     This  is 


424  KQl- 1  I'M  I •:  N  T    IX    CONSTRUCTION 

a  safeguard  which  makes  it  imperative  for  the  operator  to  keep  his 
hand  on  the  control  at  all  times,  and  if  he  does  not  do  so;  the  ele- 
vator comes  to  a  full  stop. 

Elevator  doors  should  be  of  the  differentiating  type,  in  which 
the  door  is  divided  into  sections,  all  operating  on  lever  arms,  and 
in  which  the  first  section  moves  faster  than  the  second,  and  the 
second  faster  than  the  third,  in  such  a  manner  that  when  the  first 
section  is  open,  all  the  other  sections  are  fully  opened  also.  This 
door  can   be  made  to  operate  almost  noiselessly. 

Besides  the  elevators  just  described  there  is  the  inclined  run- 
way, which  is  admirable  in  some  hospitals,  in  warm  climates  this 
can  be  put  both  in  and  outside  of  hospitals,  and  if  made  on  a  very 
gradual  slope  or  on  a  double  slope  with  spacious  landings  are 
better  than  stair  runs  in  such  hospitals.  Naturally  these  could 
not  be  used  in  many  storied  hospitals. 

Dumb  Waiters. — These  are  of  two  types,  those  operated  by 
machine,  usually  electric,  and  the  hand  power  dumb  waiter.  The 
electric  type  should  preferably  be  of  the  full  automatic  control, 
the  same  as  described  for  the  regular  elevators,  except  that  there 
are  no  buttons  in  the  dumb  waiter.  .  A  push  of  the  button  on  any 
floor  brings  the  dumb  waiter  to  that  floor,  and  by  pushing  a  but- 
ton for  any  other  floor,  the  dumb  waiter  will  go  lo  that  floor  and 
stop. 

There  are  also  the  rope  control  dumb  waiters,  which  are  run 
by  electric  or  steam  machines. 

The  full  rope  control,  rope  hand  hoist  dumb  waiters,  or  as 
they  are  sometimes  designated,  hand-power-lifts,  are  operated 
entirely  by  hand,  no  machine  power  being  used.  These  are  eoun- 
terbalanced  and  equipped  so  that  they  operate  easily.  Dumb 
waiters  and  elevators  of  this  type  are  equipped  with  automatic 
brakes.  These  brakes  should  be  supported  independently  of  the 
rest  of  the  machine,  so  that  there  will  be  no  end  thrust,  strain 
or  friction  and  unnecessary  wear.  The  shafting  should  be  of  steel, 
and  all  bearings  should  be  fitted  with  anti-friction  steel  bearings, 
of  the  pin  or  ball  type,  to  make  the  apparatus  eas\  running.  The 
cars  should  be  of  ample  capacity  and  supplied  with  strong  shelves. 

For  high  buildings,  dumb  waiters  with  band-brakes  are  pref- 
erable, so  that  the  speed  of  the  car  can  be  controlled  by  the  brake 
cord,  and  so  that  the  car  can  be  stopped  and  locked  at  any  given 
floor. 

Vacuum  Cleaning  Systems. — Modern  methods  in  hospitals 
arc  superseding  former  and  crude  unsanitary  ones.  This  is  es- 
pecially true  of  cleaning  and  scrubbing.  .Just  as  the  common 
broom  with  its  unsanitary  raising  of  dust  was  replaced  by  the  car- 


EQUIPMENT   IN   CONSTRUCTION  4:2o 

pet  sweeper,  which  removed  only  the  surface  <lust  and  dirt,  so  the 
"vacuum  broom"  has  replaced  the  carpet  sweeper.  The  differ- 
ence in  the  transition,  however,  is  decidedly  more  marked  in  re- 
sults. With  the  vacuum  system  there  is  no  dirt  or  dust,  this  being 
entirely  removed  and  conveyed  to  the  basement  and  disposed  of 
without  the  necessity  of  carrying  it  through  the  building  as  in 
the  old  methods  of  the  dust  pan,  pail  and  carpet  sweeper.  Vacuum 
systems  also  remove  the  dust  which  was  formerly  brushed  into 
the  air  by  the  old  duster,  only  to  settle  again.  The  dusting  cloth, 
shaken  out  of  the  window  when  possible  was  an  improvement,  but 
it  was  difficult  at  best  to  get  at  places  somewhat  above  the  ordi- 
nary reach  to  remove  the  dust  except  on  "cleaning  day,"  when  a 
ladder  or  chair  was  employed. 

In  modern  hospitals,  owing  to  the  necessity  for  ventilating 
rooms,  there  are  always  currents  of  air,  which  may  not  be  per- 
ceptible to  occupants  of  the  room,  but  which  are  sufficient  to  stir 
up  dust  particles  and  keep  them  in  floating  condition. 

Scrubbing  and  cleaning  systems  may  consist  of  portable  serv- 
ice, which  is  a  cleaning  system  complete  on  wheels  and  is  designed 
for  buildings  which  are  not  equipped  for  cleaning  devices.  The 
combination  compressed  air  and  vacuum  system,  in  which  a  heavy 
blast  of  air  dislodges  the  dirt  and  the  vacuum  automatically  re- 
moves the  dirt  to  dust-arresting  tanks.  This  apparatus  is  not 
ordinarily  needed  in  hospitals,  except  in  pipe  and  wire  slots,  and 
such  places  where  dust  is  liable  to  accumulate  for  any  length  ol 
time,  and  where  it  is  not  practicable  to  clean  daily.  A  vacuum 
system  consists  of  a  vacuum  pump  or  aspirator  to  obtain  vacuum, 
the  tanks  for  atomizing  and  condensing,  the  piping  to  carry  the 
dust,  and  the  cleaning  tools  and  brushes.  The  pump  can  be  driver] 
by  steam  or  electricity;  if  by  steam  it  should  have  an  automatic 
control.  The  cost  of  operating  such  a  pump  directly  connected  is 
less  than  one  cent  per  sweeper  hour.  The  electric  driven  pump 
can  be  either  direct  connected,  chain  drive  or  belt  drive.  The  bet- 
ter grades  of  these  pumps  will  operate  a  la-inch  vacuum. 

The  steam  ejectors  or  aspirators  are  used  only  where  there 
is  no  other  power.  They  are  operated  by  steam  under  pressure 
or  by  compressed  air,  but  are  not  as  economical  as  the  power- 
driven  pumps.  The  ejector  or  aspirator  takes  from  three  to  five 
times  as  much  power  to  operate  to  produce  the  same  results  as  .1 
vacuum  pump.  The  apparatus  is  placed  in  the  basement  and  the 
building  is  piped.  The  usual  method  is  to  inn  a  sufficient  number 
of  risers  up  through  the  building  with  vacuum  inlets  on  each  floor, 
so  that  convenient  lengths  of  hose  reach  all  points.  The  size  of 
these  pipes  depends  wholly  upon  the  capacity  of  the  plant.    The 


426  EQUIPMENT    IX    CONSTRUCTION 

joints  in  these  pipes  should  be  made  with  rubber  gaskets  and 
should  be  of  sufficient  size  so  that  the  system  is  permanent.  In 
making  turns  or  bends  in  the  piping  recessed,  long  turn  fittings  or 
recessed  fittings  with  bent  pipe  should  be  used. 

The  most  important  factor  in  any  cleaning  system  is  the  sep- 
aration of  the  dust  from  the  air.  This  is  done  in  the  tanks.  The 
first  or  dry  tank  removes  the  larger  percentage  of  the  dust  by 
centrifugal  motion.  The  remainder  or  lighter  particles  are  re- 
moved by  atomizing  in  the  "wet"  tank.  The  air  is  passed  through 
water  in  this  tank,  thus  washing  it  and  allowing  it  to  pass  to  the 
pump  thoroughly  cleaned,  the  circulating  water  running  to  the 
sewer. 

The  tools  consist  of  carpet  sweepers,  sweepers  for  hardwood 
and  tile  floors,  wall  brushes,  clothes  brushes,  npholstery  brushes. 
The  scrubbing  brushes  are  made  to  permit  water  to  run  into 
them  through  a  supply  hose,  the  water  being  under  control,  and 
as  the  floor  is  scrubbed,  the  vacuum  mop,  as  it  is  designated,  takes 
up  the  water.  Corridor  floors  and  floors  of  operating  rooms  es- 
pecially could  be  done  in  this  manner. 

Sterilizers  and  Disinfectors. — The  modern  hospital  is  not 
complete  without  its  sterilizing  apparatus.  There  are  many  forms 
of  sterilizers,  from  the  large  apparatus  for  surgical  dressings  to 
the  smaller  instrument  sterilizers.  The  steam  for  sterilizers  is 
derived  from  the  boiler  supply,  and  if  there  is  no  such  general 
plant,  a  plant  is  installed  for  the  purpose.  In  smaller  hospitals 
where  live  steam  is  not  available  from  a  central  point,  it  may  be 
made  for  the  sterilizers  by  a  gas  flame  or  petroleum  flame.  If 
>t«'am  from  a  central  plant  is  obtainable  it  is  used  in  the  central 
disinfecting  plant,  to  disinfect  bedding;  for  sterilizing  instruments 
in  the  operating  department;  in  the  dispensary,  dressing  and 
autopsy  department;  it  is  used  also  for  the  heating  of  thermostats 
and  apparatus  of  the  pathological  laboratory  and  the  water  baths. 
It  is  also  usi'd  in  the  kitchen,  diet  kitchens,  in  the  steam  jackets, 
coifee  urns  and  other  apparatus  for  cooking  and  keeping  food 
palatably  hot;  and  for  sterilizing  water  under  steam  pressure. 
It  will  be  evident  that  a  central  plant  to  supply  all  of  these  is  an 
economy  in  many  ways,  as  the  sterilization  could  be  done  more 
quickly  and  readily  if  the  steam  were  always  at  hand  to  turn  on 
instantly. 

For  the  operating  department  there  is  ordinarily  provided  a 
sterilizing  room,  in  which  are  the  surgical  dressing  and  instrument 
sterilizers.  These  consist  of  a  steam  jacketed,  pressure  steam 
sterilizer  of  necessary  size  to  do  the  work  adequately.  They  are 
made  in  two  forms — the  globe  form,  being  a  ball-shaped     appa- 


EQUIPMENT   IN    CONSTRUCTION  427 

ratus,  and  the  long  cylindrical  apparatus.  The  globe  form  has  a 
steam-tight  door  without  mechanical  catch  or  fastening,  the  door 
sliding  or  rolling  back  and  forth,  making  a  metal  to  metal  joint 
when  closed.  It  is  free  from  all  packing  and  gaskets,  which  is  an 
advantage  where  such  high  temperatures  are  necessary.  The 
cylindrical  form  has  a  swing  door  which  closes  into  a  rabbett,  and 
has  screw  clamps  to  bring  the  door  closely  to  the  rabbett  and  which 
must  be  fastened  securely.  Instrument  sterilizers  are  of  two 
kinds,  the  oblong  and  oval,  both  of  which  come  in  various  sizes 
and  depths.  They  are  usually  of  the  shallow  pattern  or  of  medium 
depth  with  one  or  two  trays.  Bowl  sterilizers  are  of  the  deeper 
form.  There  is  usually  one  instrument  and  one  bowl  sterilizer 
placed  in  the  sterilizing  room.  In  each  dressing  room  and  in  the 
obstetrical  department  there  is  also  one,  and  sometimes  two,  in- 
strument sterilizers. 

It  is  not  always  possible  to  have  a  central  distilling  plant  for 
obtaining  sterile  water,  in  which  case  a  sterilizing  apparatus  under 
steam  pressure,  operated  by  steam,  gas  or  petroleum,  should  be 
installed  to  obtain  sterile  water  for  surgical  operations.  Such 
sterilizers  should  have,  in  connection,  a  filter  of  the  germ-proof 
stone  form.  The  coils  should  be  removable  and  the  whole  ap- 
paratus so  constructed  that  it  is  not  necessary  to  use  wrenches  to 
remove  the  covers. 

Pathological  laboratory  equipment  depends  wholly  upon  the 
extent  of  the  work  to  be  performed  by  the  institution  in  this  line. 

There  are  also  steam  sterilizers  for  Pasteurizing  or  steriliz- 
ing milk  in  large  or  small  quantities.  Such  apparatus  is  necessa  ry 
in  all  hospitals,  but  especially  in  children's  hospitals  and  those 
hospitals  having  an  obstetrical  department, 

Steam  sterilizers  are  used  in  disinfecting  ovens.  These  are 
of  two  forms,  the  rectangular  and  the  cylindrical.  They  are  used 
for  sterilizing  mattresses,  bedding  and  clothing.  The  steam  to 
these  must  be  superheated,  dry  steam  put  into  the  ovens  at  high 
pressure,  and  the  ovens  must  not  be  opened  until  they  have  cooled 
thoroughly,  as  opening  before  this  takes  place  causes  condensation 
and  a  consequent  dampness  of  the  contents  of  the  sterilizer. 

Disinfecting  or  fumigating  as  generally  practiced  is  more  or 
less  of  a  farce.  To  be  effective  it  may  be  done  in  several  ways, 
but  the  method  most  in  use  now,  and  perhaps  the  only  positive 
method,  is  by  permanganate  of  potash  and  the  formaldehyde  gas 
process,  and  with  this  it  is  best  Jo  have  an  apparatus  for  generat- 
ing the  gas.     There  are  several  forms  in  the  market. 

It  is  an  easy  matter  to  test  the  efficiency  of  any  one  of  these 
by  placing  in  the  room  to  be  disinfected  cultures  of  bacteria  and 


4JS 


EQUIPMENT   IN   CONSTRUCTION 


also  dressings  saturated  with  wound  secretion  containing  path- 
ogenic bacteria  and  making  cultural  tests  of  these  after  the  disin- 
fection has  been  completed. 

KITCHEN  EQUIPMENT. 

STOVES,    RANGES    AND    FOOD    HEATING    APPARATUS 

In  former  years  when  hospital  kitchens  were  crude  in  their 


construction  and  more  so  in  their  equipment,  the  latter  consisted 
of  a  large  stove  or  range  placed  in  a  roomi  always  in  the  basement, 

upon  which  were  placed  huge  pots,  kettles  and  pan.,  in  which  all 


EQUIPMENT   IX    CONSTRUCTION  £29 

of  the  food  was  prepared,  and  the  odors  from  which  permeated  and 
saturated  the  entire  building  for  hours  before  and  after  each  meal, 
in  fact  continuously.  With  the  advent  of  the  many-storied  hos- 
pital this  has  been  changed,  and  we  now  have  the  kitchen  on  the 
top  floor,  along  with  a  diet  kitchen  which  is  also  a  training  room 
for  nurses  in  the  art  of  preparing  special  diets.  In  addition  to 
this  diet  kitchen  there  are  the  baking  room  and  the  auxiliary  diet 
kitchens,  one  on  each  floor  upon  which  patients  are  treated.  This 
has  brought  up  the  serious  problem  of  getting  food  to  patients 
hot  and  palatable,  and  there  has  been  consequent  elaboration  of 
equipment.  In  the  general  kitchen  is  placed  the  large  range  for 
cooking  the  ordinary  food.  Here  also,  in  large  institutions,  are 
placed  steam- jacketed  kettles  for  cooking  vegetables,  and  the 
steam-jacket  serving  table  with  its  hot  water  pan,  into  which  are 
placed  crocks  containing  food;  and  also  the  closets  for  keeping- 
dishes  warm.  This  latter  arrangement  is  so  simple  and  can  be 
run  so  inexpensively  that  it  is  somewhat  surprising  it  is  not  in- 
stalled more  often  (Fig.  267). 

The  baking  room,  which  is  separate  from  the  kitchen,  is  suit- 
plied  with  a  portable  oven  or  ovens  (depending  on  the  size  of  the 
institution)  with  all  the  necessary  equipment  for  baking. 

The  special  diet  kitchen  is  furnished  with  a  range,  or  prefer- 
ably a  number  of  small  gas  stoves  for  preparing  special  diets. 

The  diet  kitchens  on  each  floor  are  fitted  with  a  gas  stove  and 
a  steam-jacketed  warming  oven,  as  described,  and  sometimes  a 
coffee  urn. 

In  some  hospitals  all, the  food  is  prepared  in  the  main  kitchen 
and  sent  down  the  dumb  waiters  to  the  respective  floors  in  cov- 
ered dishes,  and  served  on  trays  in  the  diet  kitchens.  In  others 
the  food  is  placed  on  trays  in  the  main  kitchen  and  put  on  specially 
prepared  carts,  which  are  kept  hot  by  a  hot  water  jacket  (in  tact. 
a  portable  oven),  each  floor  having  its  own  carts,  and  a  porter 
taking  these  to  the  wards,  where  the  trays  are  then  distributed 
by  the  nurses.  The  diet  kitchen  on  each  floor  in  such  cases  acts 
as  an  auxiliary  for  the  preparation  of  special  diets  served  between 
meals,  and  also  for  keeping  local  supplies,  such  as  milk,  in  the  re 
frigerators. 

All  ranges  in  kitchens  should  be  built  with  properly  ventilated 
hoods  (as  also  the  gas  ranges  in  the  diet  kitchens),  and  the  steam 
tables  should  be  placed  under  such  hoods,  having  properly  con- 
structed vents.  The  kitchen  range  in  larger  hospitals  should  be 
placed  in  the  middle  of  the  room,  so  that  it  is  accessible  from  all 
sides — the  stack  running  straight  up  through  the  roof  and  made  in 


430  EQUIPMENT   IN   CONSTRUCTION 

such  a  manner  that  the  heated  stack  will  act  as  a  means  of  venti- 
lating the  entire  kitchen. 

THE  LAUNDRY. 

The  fitting  up  of  the  laundry  in  hospitals,  depending  as  it 
does  entirely  upon  the  amount  of  work  to  be  handled,  can  cover 


only  in  a  general  way  what  the  room  should  be  and  what  ma- 
chines are  necessary  to  do  the  work  with  as  few  hands  as  possi- 
ble  the  Qumber  of  such  machines  depending  upon  the  require- 
ments. Labor  is  expensive,  hence  all  machines  that  wdl  eliminate 
it  and  facilitate  the  work  of  the  hospital  mighj  rightly  be  termed 
necessary.- 


EQUIPMENT   IN    CONSTRUCTION 


431 


No  part  of  a  hospital  Deeds  greater  care  as  to  the  arrange- 
ment and  equipment  than  the  laundry,  for  upon  this  department 
depends  to  a  great  extent  the  cleanliness  of  the  institution.  In 
equipping  a  plant  it  is  always  advisable  to  ascertain  the  capacity 
of  various  machines  and  their  operation. 


f 


I.  P 

C/q    t'O 
Oi 

o   * 
o 


Room. — The  laundry  should  he  in  a  separate  building,  if  pos- 
sible, for  many  reasons,  the  most  important*  of  which  is  to  pre- 
vent the  odors  from  passing  through  the  hospital  proper.  Should 
a  location  of  this  kind  not  be  possible,  then  the  room  in  which 
the  work  is  to  be  done  must  be  provided  with  as  many  ventilating 
shafts  as  practical.     This  room  should.be  ventilated  by  at  leasi 


432 


EQUIPMENT   IX   CONSTRUCTION 


two  vent  shafts,  one  being  absolutely  necessary  for  modern  dryers 
and  the  other  for  the  room  ventilation.  Windows  will  not  always 
answer  for  this  purpose,  owing  to  the  fact  that  odors  going  out 
of  windows  will  rise  along  the  wall  and  enter  other  windows  above. 
Light  and  air  are  very  essential  and  all  that  can  be  obtained 
should  bo  given,  as  the  laundry  at  its  best  is  a  hot  and  steamy 
room.  The  height  of  the  room  should  bo  as  near  ten  feet  as  pos- 
sible. 

The  floor  should  be  of  concrete  with  a  cement  top,  water- 
proofed as  described.  A  general  gutter  having  one  outlet  (at 
least  four  inches)  should  be  provided.  This  gutter  should  be 
built  in  and  be  a  part  of  the  floor  and  placed  directly  under  the 


fig.  270. 

washers  and  tubs  with  drains  running  from  any  place  in  the  room 
where  there  is  water.  These  drains  should  be  iron  pipes  laid  in 
the  floor  running  from  the  points  necessary  and  placed  in  the  con- 
crete at  the  time  the  latter  is  laid.  The  sewer  outlet  should  be 
protected  by  a  screen  to  prevent  lint  or  other  substances  from 
stopping  up  the  pipe.  All  machines  should  drain  into  this  gutter 
and  should  never  be  connected  directly  to  the  sewer  proper,  as 
some  article  might  gel  into  these  pipes  which  could  not  be  readily 
removed.  This  applies,  however,  only  to  tubs  in  the  Laundry.  A 
gutter  plan  is  here  shown  (Fig.  270). 

The  depth  and  width  of  the  gutter  should  be  governed  by  the 
amount  of  water,  or  the  number  of  machines  io  be  taken  care  of. 
The  cement  floor  should  have  a  gradual  slope  of  about  one  inch 


EQUIPMENT   IX    CONSTRUCTION  433 

to  three  feet,  so  that  all  of  the  water  will  run  Into  the  gutter. 
thus  making  it  possible  for  the  floor  to  be  easily  cleaned  by 
flushing  with  a  volume  of  water.  The  gutter  proper  should  have 
a  low  point  at  which  should  be  placed  a  trap  sewer  connection. 

Steam. — The  first  essential  of  an  economically  operated  laun- 
dry is  the  steam  supply,  and  in  putting  in  a  boiler  for  this  pur- 
pose it  is  advisable  that  it  have  high  pressure  of  not  less  than 
forty  pounds  and  not  necessarily  over  one  hundred.  Should  one 
boiler  only  be  desired  for  furnishing  all  steam  supply  Tor  the 
institution,  it  should  be  so  arranged  as  to  bo  direct  connected  to 
the  laundry  and  provided  with  reducers  on  all  lines  not  requiring 
high  pressure.  Modern  laundry  machines,  such  as  steam  mangles 
and  dryers,  require  high  pressure  The  higher  the  pressure  the 
better  will  be  the  results.  The  boiler  room  should  be  as  near  the- 
laundry  as  possible,  but  in  every  instance  in  another  room  or 
building.  A  good  plan  is  to  have  a  separate  power  plant  with  tin' 
laundry  above  the  boiler  room.  This  room  should  be  equipped 
with  steam  feed  water  pump  and  hot  water  storage  tank  for  boiler 
supply. 

Water. — A  liberal  supply  of  hot  and  cold  water  should  be 
furnished  the  laundry,  and  in  all  cases  should  run  through  gal- 
vanized iron  pipes.  These  pipes  should  never  be  smaller  than  one 
inch,  and  impossible  one  and  one-half  to  three  inches,  depending 
upon  the  number  of  machines  to  be  supplied  and  the  amount  re- 
quired for  them.  The  cold  water  as  a  general  thing  is  not  hard 
to  obtain,  but  hot  water  must  be  supplied.  A  storage  tank  for 
this  purpose  must  be  provided.  Should  the  tank"  for  the  boiler 
supply  be  large  enough,  then  hot  water  for  the  laundry  can  be 
taken  from  this  or  from  the  house  hot  water  tank,  as  described 
in  Plumbing. 

Power. — The  power  to  drive  the  machinery  has  been  described 
in  the  chapter  on  Electric  Work.  Conditions  strongly  recommend 
direct  connected  electric  motors  on  each  machine  as  stated.  \\  itll 
this  manner  of  drive  power  is  used  only  when  the  machine  is  in 
operation.  Besides  this  advantage  it  lias  many  good  qualities, 
SUCh  as  ease  of  operation,  absence  of  noise  and  dirt  caused  by 
running  belts,  is  not  dangerous  and  is  readily  put  into  service. 
The  general  opinion  is  thai  it  would  cosl  more  tc  operate  laundry 
machinery  by  the  individual  motor  driven  than  with  a  steam  en- 
gine, but  this  has  been  disproven  in  many  cases,  as  with  a  steam 
engine  the  additional  cost  of  coal  will  generally  pay  for  the  cosl 
of  electric  current.  'Die  steam  engine,  however,  is  satisfactory, 
but  requires  the  services  of  a  competent   man. 

(hie  motor  of  sufficient   size  can  also  be  used  to  operate  the 


434 


EQUIPMENT  IN   CONSTRUCTION 


entire  equipment,  but  the  disadvantage  of  this  is  that  the  belt  and 
power  used  to  drive  the  machines  must  run  at  all  times  even  under 
minimum  load,  as  would  be  the  ease  if  part  of  the  machinery  was 
in  use  and  part  idle.  Gas  engines  are  never  advisable,  principally 
■on  account  of  the  noise,  smell  and  great  care  needed  to  keep  them 
in  operating  condition.  If  bell  power  is  used,  substantial  shaft- 
ing- must  be  provided  in  good  hangers. 

In  the  washing  department  the  best  double  leather  belting 
should  be  used,  as  these  belts  are  subject  to  great  strain  when  the 
machines  are  in  operation.  They  are  constantly  being  shifted 
from  one  pulley  to  another  and  this  department  being  damp,  a 
pooi-  belt  would  deteriorate  quickly.  Should  the  power  be  de- 
rived from  belt  drive,  great  care  should  also  be  taken  that  there 
be  no  noise  or  vibration.  These  can  he  overcome  by  pipe  frame 
shafting  construction.  Any  dangerous  belts  should  be  protected 
by  shields. 

MACHINERY. 

Sterilizer.— There  should  be  placed  in  the  laundry  steriliz- 
ing and  disinfecting  machines,   through  which  all  goods   should 


fig.  271. 

pass.  These  machines  are  so  constructed  that  they  will  thor- 
oughly disinfect  all  classes  of  hospital  goods.  They  are  made 
with  a  steam  chamber  with  an  inner  and  outer  steel  shell,  which 
forms  a  steam  jacket,  having  east  iron  ends  and  frames  in  which  the 
doors  are  fitted  with  steam  pipe  copper  gaskets.  These  doors  are 
placed  at  both  ends  and  the  machine  should  be  installed  so  that 
one  end  is  in  the  soiled  linen  room  and  the  other  in  the  laundry 
(Fig.  271),  making  it  necessary  that  all  goods  must  pass  through 
the  sterilizer  and  be  disinfected  before  entering  the  laundry.  The 
door  opening  into  the  laundry  room  should  first  be  closed,  after 


EQUIPMENT   IN    CONSTRUCTION 


4.;;) 


which  the  goods  are  placed  in  a  wire  basket  which  is  run  into  the 
machine.  The  other  door  is  then  closed  and  steam  turned  into  the 
jacket,  which  remains  filled  with  steam  during  the  entire  operation, 
thus  making  the  chamber  a  drying  oven.  In  this  manner  arti- 
cles in  the  machine  are  brought  to  a  high  temperature  before  the 
admission  of  steam  to  the  inner  chamber,  and  are  thoroughly  dried 
after  the  steam  has  been  exhausted.  This  machine  is  fitted  with 
an  air  pump  whereby  a  vacuum  of  fifteen  to  twenty  inches  is  pro- 
duced previous  to  the  admission  of  steam  to  the  inner  chamber 
(Fig.  272). 

Sterilizing  Washer. — There  are  also  machines  known  as 
sterilizing  washers,  built  entirely  of  metal  having  thumb  screws 
to  hold  the  covers  tightly.  Vent  pipes  run  to  an  exhaust  fan  or 
ventilating  shaft  from  these  machines.    After  the  goods  are  placed 


fig.  272. 

in  the  machine  the  door  is  securely  fastened  and  steam  turned  on, 
after  which  the  goods  are  washed  in  the  regular  way. 

This  form  of  disinfecting  is  not  as  thorough  as  that  with  a 
sterilizing  machine.  The  greatest  danger  in  using  this  machine 
is  the  possible  contact  of  germ-laden  goods  with  goods  already 
laundered. 

Washers. — Washers  for  hospital  laundries  should  be  made 
entirely  of  brass  or  with  brass  cylinders  and  galvanized  shells. 
They  should  be  so  constructed  for  two  reasons — first,  because 
they  are  subjected  to  severe  usage  owing  to  the  nature  of  the 
work  performed,  and  second,  because  machines  buill  in  tliis  man- 
ner are  the  most  sanitary.  These  machines  are  made  with  many 
combinations,  such  as  those  constructed  wholly  of  wood;  those 
of  wood  with  the  exception  of  the  iron  outer  shell  heads;  those 
of  brass  with  galvanized  iron  shells  and  iron  shell  heads  (Fig*. 
273),  and  those  built  entirely  of  brass.  Those  made  with  iron 
bearing  standards  greatly  add  to  the  life  of  the  machine. 


430 


EQUIPMENT    IX    CONSTRUCTION 


All  machines  are  of  the  same  general  type,  but  there  are 
some  t<»  be  obtained  which  are  economical  in  the  use  of  time  and 
materials  required  to  gel  the  desired  results.  All  washers  should 
be  equipped  with  a  steam  siphon,  as  live  steam  blowing  into  the 
linen  greatly  injures  the  goods  by  separating  the  fillers.  The  re- 
versing movement   which  is  necessary  in  washing  machines  must 


fig.  273. 

be  absolutely  the  same  one  way  as  the  other  to  protect  the  con- 
tents of  the  machine  from  becoming  badly  tangled  and  torn. 

Extractor. — This  machine  is  built  to  extract  the  water  from 
the  goods  after  being  washed  and  does  its  work  by  centrifugal 
force.  The  goods  are  placed  in  a  copper  basket  which  has  numer- 
ous  perforations   and   which   is   supported  by  steel  hoops.     This 


fig.  274. 

baskel  is  built  on  a  steel  vertical  shaft,  at  the  bottom  of  which 
is  placed  the  driving  pulley  (Fig.  274).  Owing  to  the  high  speed 
at  which  the  baskel  travels  this  machine  is  dangerous  and  it  is 
essential  that  the  i»e>t  must  he  procured.  One  having  a  cast  iron 
outer  casing — cast  with  the  curb-holding  balancing  rubber  springs 
and  provided   with  a   safety   rubber  bumper  so  that  the  basket 


EQUIPMENT    IN    ntNSTlin    1 10M 


4:57 


absolutely  cannot  strike  the  shell  should  same  be  unevenly  loaded 
—is  the  best  (Fig.  275). 

Soap  Tank— Whether  the  hospital  manufactures  its  own  soap 
from  tallow  and  soap  stock,  or  purchases  a  ready-made  soap,  a 
soap  tank  made  of  galvanized  iron  is  necessary  to  saponify  to  a 
Liquid  the  chip  soap  that  is  generally  used.  This  tank  should  be 
round  and  supplied  with  a  circular  steam  coil  placed  in  the  bottom, 
this  to  be  capped  on  The  end  and  have  small  holes  about  three 
inches  apart  so  that  the  steam  can  penetrate  to  all  parts  of  the 
tank.  A  water  supply  should  he  run  to  this  tank  and  both  steam 
and  water  connections  made  so  that  they  can  he  easily  removed, 
to  allow  the  tank  to  be  cleaned. 

Wash  Tubs. — As  described  under  Plumbing,  stone  or  porce- 


fig.  275. 

lain  tubs  of  not  more  than  three  sections  should  be  placed  m 
every  laundry,  and  each  section  should  be  furnished  with  hoi 
and  cold  water,  and  one  section  with  a  brass  boiling  pipe  (us  de- 
scribed for  soap  tanks)  to  boil  water.  This  brass  steam  pip- 
should  be  connected  with  a  swinging  joint  so  thai  the  pipe  can  be 

lifted  up. 

Starch  Cookers.— Some  provision  should  be  made  for  cook 
ing  starch,  as  there  is  always  need  for  starch  in  the  smallesl  in- 
stitution. This  can  be  done  by  having  a  steam  pipe  arranged  so 
that  it  can  be  inserted  into  a  pail.  For  many  reasons,  principally 
the  waste  of  starch,  this  is  uot  a  good  process,  for  nil  that  is  made 
and  not  used  in  this  manner  is  generally  thrown  away.  Starch 
cookers,  therefore,  should  be  provided.  These  are  made  with  an 
inner  lining  of  copper  and  an  outer  casing  of  galvanized  iron 
between  which  there  is  mineral   wool  and  asbestos,  which  makes 


4.-5S 


K(,H  ■  I I'MEXT   IX    CONSTRUCTION 


it  heat-retaining  and  keeps  the  starch  hot  for  a  long  time.  These 
heaters  should  be  supplied  with  automatically  working  covers  and 
condensing  traps  to  separate  the  condensed  water  from  the  steam 
so  that  steam  only  enters  the  starch.  Enough  starch  can  he  cooked 
ai  a  time  to  last  in  most  cases  a  week  without  spoiling  (Fig.  276). 


fig.  276. 
Stabching  Machines.— The  only  machines  of  this  kind  used 
in  hospitals  are  those  commonly  known  as  dip  wheels,  which  are 
used  for  starching  collars  and  cuffs,  but  this  work  can  be  done 
by  hand  unless  there  is  a  great  quantity  of  it. 


fig.  277. 

Dry  Rooms.— Dryers  buill  in  sections  and  put  together,  form- 
ing a  cabinet,  are  the  best  for  hospital  purposes.    They  arc  either 

built  of  all  metal  (Fig.  277)  or  of  wood  lined  with  asbestos  and 
block  tin  (Fig.  278),  making  them  practically  fireproof.  They  are 
easy  to  clean  and  to  keep  clean.     The  clothes  trucks  run  on  the 


EQUIPMENT   IX    CONSTRUCTION 


439 


floor  and  can  be  taken  to  any  part  of  the  room,  which  allows  one 
to  enter  the  dryers  as  they  -would  a  large  refrigerator.  The  heat 
is  derived  from  three  steam  coils,  standing  vertically  in  the  room, 
one  at  each  side  and  one  in  the  center  almost  completely  sur- 
rounding the  trucks  on  which  the  clothes  to  be  dried  are  hung. 
These  rooms  hold  two  trucks  at  a  time  and  as  three  are  furnished, 
allows  one  to  be  unloaded  and  reloaded  while  the  others  are  drying. 
Other  commendable  features  of  these  dryers  are  the  circulating  !';m 
in  the  top,  which  drives  the  heat  to  the  bottom  and  forces  the 
moisture  out  through  the  ventilating  pipe  (which  must  be  sup- 
plied) greatly  facilitating  the  speed  of  the  drying.  Under  ordi- 
nary conditions  with  eight  pounds  pressure  of  steam  these  dryers 
will  perform  their  work  in  thirty  minutes.  The  space  taken  up  is 
very  small  in  comparison  with  the  draw  dryers  of  similar  capacity. 
A  good  steam  trap  should  be  installed  with  the  dryer,  allow- 


fig.  278. 

ing  all  the  water  to  escape  and  holding  back  the  dry  steam,  thus 
keeping  the  pipes  clear  of  water  and  as  hot  as  the  steam  will  make 
them.  It  would  be  well  to  return  this  condensed  water  to  a  tank 
to  be  used  for  the  washing  of  flannels  and  delicate  fabrics. 

Mangles. — The  mangle  is  one  of  the  most  importanl  ma- 
chines in  laundry  equipment.  In  all  modern  laundries  flat  work 
is  never  dried,  as  it  is  taken  direct  from  the  extractor  and  fed 
through  the  mangle.  High  steam  pressure  is  absolutely  necessary 
to  obtain  results  from  these  machines.  A  machine  with  a  heated 
cylinder,  the  size  to  he  governed  by  the  amounl  of  work  to  he  done, 
is  the  best.  They  are  mad"  with  cylinders  16,  _4  and  48  inches 
in  diameter,  by  48,  64,  75,  !<",  !<»<)  and  120  inches  in  length,  around 
which  at  various  angles  are  placed  auxiliary  rolls,  which  rolls 
are  covered  with  wool  covering  and  between  which  pas>  I  he  goods 
being  dried  and  ironed  (Fig.  279).  A  cylinder  machine  having  a 
lower  apron  attachment   by   which  the  goods     pass     completely 


440 


EQUIPMENT   IN   CONSTRUCTION 


around  the  cylinder,  being  deposited  upon  a  table  directly  under 
the  feed  into  the  machine  (  Pig.  280),  and  which  allows  the  work  to 
be  handled  by  two  operators,  is  by  far  the  most  desirable  for  an 
institution  handling  about  three  thousand  pieces  per  day.    If  the 


institution  has  more  than  the  above  number  of  pieces  to  launder, 
it  would  be  necessary  to  Lave  a  machine  having  a  second  lower 
apron  attachment,  which  would  carry  the  goods  to  the  opposite 
side  from  which  they  are  fed  (Fig.  281),  after  they  have  made  a 
complete  circuit  of  the  cylinder,  which  allows  the  feeders  to  do 


EQUIPMENT    IN    CONSTRUCTION 


441 


nothing  else  and  requires  folders  where  the  goods  come  out. 
Cylinder  machines  are  preferable  to  other  tonus,  because  they  are 
much  easier  on  the  linen,  cheaper  to  maintain  and  the  space  re- 
quired is  smaller  for  their  installation.  They  are  easier  on  the 
linen,  especially  the  hems,  because  the  cylinder,  auxiliary  rolls 
and  the  goods  travel  together;  cheaper  to  maintain,  because  the 
wool  covered  rolls  come  in  contact  with  the  heated  surface-  at  a 
point  of  contact  of  less  than  one  inch,  and  that  the  steam  rising 
from  the  damp  goods  escapes  instead  of  penetrating  the  blankets, 
which  soon  rots  them.  No  mangle  should  be  considered  unless  it 
has  an  automatic  apron  feed,  as  shown  in  the  illustrations,  for 
without  it  it  is  impossible  to  feed  the  goods  straight  and  without 


"''"' W»'."'-J-t-„,H 


fig.  280. 
turned  edges,  but  more  important  than  this,  it  absolutely  prevents 
the  operators  from  being  caught  in  the  machine  while  feeding.     A 
steam  trap  should  also  be  connected  with  this  machine,   for  the 
same  reason  as  referred  to  in  regard  to  dry  rooms. 

Body  Ironer.— The  body  ironer  (Fig.  282)  derives  its  name 
from  the  fact  that  it  was  first  used  by  Launderers  for  ironing  shirl 
bodies,  but  now  used  to  iron  underwear,  aprons,  coats,  skills, 
stockings,  handkerchiefs  and  almost  any  other  garment  thai  must 
be  ironed.  The  principle  of  the  machine  is  the  same  as  that  of 
the  mangle.  Two  rolls,  one  hot,  the  other  padded,  are  pressed 
together  and  revolved  at  the  will  of  the  operator,  and  between 
which  the  articles  being  ironed  are  placed.  This  machine  with 
one  operator  can  easily  do  the  work  of  four  hand  ironers,  and  in 
many  small  institutions  takes  the  place  of  the  mangle.  The  roll 
is  heated  by  electricity  or  gas. 


441' 


EQUIPMENT   IN    CONSTKUCTION 


Ironing  Boards. — In  every  laundry  there  should  be  at  least 
two  ironing  boards,  built  on  iron  bases  equipped  with  sleeve 
boards.  If  gas  heated  irons  are  to  be  used,  these  boards  should 
be  fitted  with  sad  iron  heaters. 

Irons. — The  use  of  electrically  heated  flat  irons  is  recommend- 
ed, as  they  are  both  economical  and  clean.  If  the  ordinary  irons 
arc  used,  gas  sad  iron  heaters  made  especially  for  heating  flat 
irons  should  be  provided. 

Accessories. — Bleach  and  bluing  jars  are  necessities  in  all 
well-equipped  laundries,  as  are  also  scales,  graduated  glasses  and 
measures.  All  work  in  the  washing  and  starching  departments 
should  be  exact. 


FIG.   281. 

All  steam  pipes  should  be  well  covered  with  asbestos  pipe 
povers. 

If  the  institution  is  a  large  one  in  which  it  is  necessary  to 
launder  on  an  average  of  five  thousand  pieces,  or  over,  a  day,  u 
machine  known  as  a  Tumbler  should  be  installed.  Its  work  is  to 
take  the  goods  as  they  come  from  the  extractor,  where  they  are 
packed  in  a  solid  mass,  and  shake  them  up  to  remove  all  lint,  etc., 
making  a  great  saving  in  the  labor  required  to  shake  the  goods 
out  before  they  can  be  fed  into  the  mangle. 

Should  there  be  a  considerable  number  of  collars  and  cuffs, 
say  more  than  can  be  ironed  in  an  hour  by  hand,  a  small  ironer 
for  this  purpose  should  be  provided.  These  machines  are  made 
with  a  heated  and  a  padded  roll,  between  which  the  collars  pass 
in  such  a  manner  that  a  much  greater  pressure  is  obtained  than 
is  possible  on  a  body  ironer  or  by  hand. 

The  laundry  should  be   supplied  with  a  curtain     stretcher. 


EQUIPMENT    IN    CONSTRUCTION 


443 


Frames  of  many  kinds  arc  made  for  this  purpose,  but  the  best 
of  these  are  made  of  galvanized  iron  pipe  having  adjustable  cor- 
ner sockets,  or  in  the  form  of  curtain  trucks,  which  can  be  run 
into  the  regular  dry  rooms. 

Blanket  Drying  Closets. — In  all  modern  hospitals  there 
should  be  provided  on  each  floor  upon  which  there  are  patients, 
a  space  or  room  in  which  blankets  can  be  quickly  and  readily 
dried.  Such  space  need  only  be  large  enough  to  admit  a  drying 
rack  on  which  the  blankets  can  be  hung.  It  is  not  convenient  nor 
expedient  to  carry  all  blankets,  which  have  become  damp  or  wet 
in  the  treatment  of  typhoid  cases,  or  from  other  causes,  to  the 
basement  or  roof. 


fig.  282. 

The  simplest  form  of  such  a  drying  rack  could  be  made  by 
placing  wooden  poles  horizontally  in  a  closet  off  the  bathroom 
over  which  the  blankets  can  be  hung,  and  into  which  closet  are 
introduced  steam  coils  or  some  form  of  heating.  A  sliding  rack 
could  also  be  run  on  tracks  into  a  narrow  room,  or  in  part  of  a 
room,  for  this  purpose.  A  small  drying  room  such  as  is  provided 
for  laundries  would  be  admirable  in  the  latter  case,  as  thi-  could 
be  heated  by  steam  or  gas. 

A  space  could  be  provided  also  for  this  purpose  by  building  a 
slot  about  three  feet  wide,  and  a  sliding  rack  either  on  tracks  or 
on  overhead  track,  and  when  the  blankets  were  on  the  racks  or 
when  the  drier  was  not  in  use  could  present  on  the  exposed  side  ;i 
panel  which  would  be  flush  with  the  wall  of  the  room  in  which 
the  rack  was  placed.  AH  spaces  for  drying  blankets  must  We  thor- 
oughly ventilated,  ami  should  under  all  circumstances  he  access! 
ble  for  cleaning  purposes. 


CHAPTER  XXV.    • 

HOSPITALS     FOR    TOWNS     OF     ABOUT     >,000 

INHABITANTS. 

Every  town  containing  five  thousand  or  more  inhabitants 
must  eventually  organize  and  conduct  a  hospital.  In  these  towns 
there  will  be  a  sufficient  number  of  persons  who  have  elsewhere 
experienced  the  benefits  of  hospital  care  to  demand  the  same  facili- 

tis  for  themselves  and  their  friends  at  heme. 

Formerly  only  the  gravest  cases  were  sent  away  to  hospitals 
for  treatment,  and  the  too  frequent  unfavorable  results  from  the 
treatment  of  these  hopeless  cases  did  not  serve  to  make  such  in- 
stitutions popular.  During  the  past  seventy  years  all  of  this  has 
been  changed,  and  there  are  now  thousands  to  sing  the  praises  of 
these  institutions,  and  the  incentive  for  building  them  lies  in  the 
fact  that  they  will  be  an  advantage  to  the  community,  and  more 
especially  an  advantage  to  the  physicians  who  will  be  active  in 
their  organization  and  maintenance. 

To  build  one  of  these  institutions  represents  one  of  the  oppor- 
tunities of  the  present  century.  There  is  always  an  opportunity 
in  hospitals,  as  well  as  industries,  during  their  rapid  development, 
and  those  who  are  active  in  these  enterprises  may  utilize  all  exist- 
ing precedents  to  great  advantage  in  their  work  without  being 
hampered  by  precedents  in  their  development.  The  effect  of  this 
truth  is  well  shown  in  comparing  the  organization  and  conduct  of 
many  of  the  hospitals  in  the  newer  with  those  in  the  older  cities. 
In  the  former  the  spirit  of  progress  is  found,  while  in  the  latter 
progress  is  often  greatly  curtailed  by  custom  and  routine,  which 
must  necessarily  endanger  the  success  of  these  institutions.  This 
objection  is  very  apt  to  come  from  lack  of  .judgment  in  persons 
at  the  head  of  the  institution,  but  this  fact  must  be  accepted  in  the 
development  of  all  industries.  There  must  be  lack  of  judgment, 
Lack  of  experience,  lack  of  qualifications  to  guard  against,  in  order 
to  secure  the  success  of  any  competitive  undertaking. 

So  far  experience  has  established  what  is  best  regarding  loca- 
tion of  a  hospital,  position  of  the  buildings,  arrangement  of  the 
finances,  organization  of  nUrsing  staff  and  servants,  etc.  In  a  few 
instance-  satisfactory  buildings  have  been  constructed  from  the 
standpoint  of  convenience,  economy  and  safety. 


HOSPITALS  FOR   TOWNS   OF   ABOUT   5,000   INHABITANTS  44-"> 

Regarding  the  organization  of  the  medical  staff,  there  is  as 
yet  no  satisfactory  precedent  for  hospitals  in  towns  whose  popu- 
lation is  not  sufficient  to  support  more  than  one  of  these  institu 
tions. 

Location.— The  greater  number  of  hospitals  in  cities  of  not 
over  five  thousand,  or  less  than  three  thousand,  inhabitants,  have 
been  located  somewhere  near  the  center  of  the  city,  the  same 
principle  being  applied  in  the  choice  of  a  location  for  a  hospital 
as  would  be  used  for  a  mercantile  house  or  a  postolnce,  with  ths 
idea  that  accessibility  would  result  in  patronage.  In  many  in- 
stances the  physicians  interested  have  determined  the  location  to 
suit  their  own  personal  convenience — near  the  center  of  the  city, 
within  walking  distance  from  their  offices  or  their  homes;  and  then 
it  often  happens  that  within  a  few  years  the  location  is  found  most 
unsatisfactory,  with  the  result  of  abandoning  the  site  and  estab 
lishing  a  new  hospital  in  a  suitable  location,  or  more  frequently 
a  competing  hospital  organization  builds  a  second  hospital  in  a 
better  location. 

The  various  sisterhoods  have  shown  better  judgment  in  the 
choice  of  location  because  of  their  natural  heed  to  precedent. 

The  best  location  for  one  of  these  village  hospitals  would  be 
a  mile  from  the  edge  of  the  town,  not  nearer  than  one-half  mile 
from  a  railroad  track,  nor  one-eighth  of  a  mile  from  a  street  cai 
track.  It  should  be  near  a  good  highway  for  the  convenience  of 
carriages  and  ambulances.  The  hospital  grounds  should  contain 
at  least  five  acres,  and  as  much  more  as  can  be  secured.  A  tVu 
hospitals  in  this  country  are  superbly  located  on  grounds  which 
previously  served  as  private  parks,  and  were  donated  for  the  pur 
pose  by  their  former  owners.  In  many  of  the  older  villages  it  is 
possible  to  purchase  such  grounds  at  a  reasonable  price,  or  it  is 
possible  to  procure  a  small  farm  for  the  purpose.  These  rather 
distant  locations  have  always  proved  very  satisfactory  Besides 
providing  a  proper  permanent  home  for  the  institution,  it  tends  to 
eliminate  from  the  institution  many  meddlesome  members  of  the 
medical  profession  who  would  find  it  inconvenient  to  travel  a  mile 
in  order  to  visit  an  institution  in  which  they  had  only  a  negative 
interest.  On  the  other  hand,  the  competent,  industrious  members 
of  the  profession  will  go  to  the  hospital  with  regularity  and  will 
not  object  to  the  extra  time  spent   in  reaching  it. 

The  higher  the  grounds  the  better,  because  of  the  advantage 
this  gives  in  securing  good  ventilation  and  drainage. 

Position  or  Buildings.— The  best  arrangement  as  regards  po- 
sition for  these  buildings  can  be  obtained  by  planning  a  long, 
narrow  building  with  a.  central  hall  running  north  ami  south.     This 


446  HOSPITALS  FOB   Tow  \S  OF  ABOUT  5,000   INHABITANTS 

insures  either  morning  or  afternoon  sun  for  every  room  in  the 
hospital  and  midday  snn  for  the  '-(Mitral  hall. 

Size  of  Hospital.  The  size  of  the  hospital  should  depend 
upon  the  size  of  the  town,  the  prospects  for  rapid  growth,  the  pop- 
ulation of  the  country  tributary,  and  more  especially  <>n  the  sJd.ll 
of  the  members  of  the  profession  who  are  in  charge  of  the  insti- 
tution. In  a  genera]  way  it  may  be  said  that  it  is  not  wise  to  plan 
a  hospital  with  less  than  sixty  beds  for  a  town  of  six  thousand 
inhabitants  or  over.  Bather  than  construct  a  hospital  that  would 
he  found  too  small  within  five  years'  time,  it  would  he  better  to 
occupy  temporary  quarters  for  a  few  years,  and  during-  this  time 
secure  permanent  grounds  and  plan  the  permanent  structure. 

There  are  three  methods  which  may  he  followed  in  order  to 
secure  a  hospital  sufficient  in  size  to  satisfy  the  future  conditions. 
These  methods  may  he  employed  individually  in  any  given  institu- 
tion, or  they  may  all  be  combined. 

First — The  hospital  may  be  so  arranged  that  ultimately  the 
entire  building  can  be  utilized  for  housing  patients.  In  the  mean- 
time, while  the  patronage  of  the  institution  is  still  insufficient  to 
require  the  entire  building,  the  top  floor  may  be  used  for  operat- 
ing rooms,  kitchen,  and  dining  rooms.  The  remaining  rooms  on 
the  floor  may  be  occupied  by  the  nurses  as  a  temporary  home. 

After  assfgning  the  necessary  rooms  for  office  and  waiting 
room,  the  first  floor  may  be  used  temporarily  by  the  matron,  the 
servants  and  the  resident  physicians.  In  case  this  does  not  supply 
a  sufficient  amount  of  space,  the  first  and  second  floors  may  be 
utilized  for  this  purpose  and  the  remaining  floors  serve  as  wards 
and  rooms  for  the  patients.  When  the  patients  become  so  numer- 
ous that  more  space  is  needed,  the  nurses  may  be  moved  to  rented 
quarters  and  later  on  the  servants  may  be  moved.  When  the 
requirements  demand  it,  a  separate  building  for  the  offices  and 
home  for  nurses  and  servants  may  be  built.  It  would  not  be  nec- 
essary to  make  this  building  fireproof  in  localities  where  such 
construction  would  be  much  more  expensive.  With  the  aid  of 
stand  pipes  and  properly  constructed  lire  escapes  such  a  home 
and  administration  building  would  be  perfectly  safe,  as  it  would 
be  occupied  entirely  by  able-bodied  adults 

The  second  method  of  enlargement  would  be  to  add  to  the 
tirst  plan  one  or  more  blank  stories,  containing  only  the  outer 
walls,  the  windows  and  the  inside  Are  walls  no  partitions,  plumb- 
ing, floors,  doors  or  heating  apparatus.  With  this  arrangement 
it  would  be'possible  to  add  at  any  time  from  fifty  to  a  hundred  per 
cent,  to  the  capacity  of  the  institution  at  a  small  additional  cost. 

The  third  method  would  be  the  building  <>!'  a  structure  ulti- 


HOSPITALS   FOR   TOWJfS   OF   ABOUT   5,0U0   INHABITANTS  4-1:7 

mately  to  be  used  for  nurses  and  servants,  which  could  at  first 
be  used  for  patients,  and  then  in  due  time  construct  an  entirely 
separate  building  for  them. 

A  fourth  plan  has  been  tried,  both  as  an  independent  scheme 
or  in  connection  with  one  or  more  of  the  above  methods.  This 
consists  in  putting  up  a  central  building  originally  and  then  to 
increase  in  the  form  of  additional  pavilions.  Eventually  this 
plan  will  undoubtedly  be  adopted,  though  up  to  the  present  time 
the  results  have  not  been  satisfactory,  owing  to  the  inconvenience 
of  the  arrangement,  and  the  unsightly  exteriors.  With  the  im- 
provement in  hospital  construction  these  unsatisfactory  elements 
will  gradually  be  eliminated,  as  the  original  plans  will  be  Likely  to 
contain  the  conditions  necessary  to  satisfy  the  future  require- 
ments. 

Organization. — The  principles  underlying  the  organization 
of  these  hospitals  are  the  same  as  those  which  obtain  in  the  organ- 
ization of  hospitals  in  large  cities.  Hospitals  in  smaller  towns 
have,  however,  this  great  advantage,  that  they  can  secure  men  to 
act  as  trustees  who  have  the  respect  of  the  entire  community.  This 
one  fact  alone  adds  strength  to  an  institution.  The  number  of 
trustees  selected  should  be  not  less  than  five,  nor  more  than  fifteen. 
The  board  of  Trustees  should  be  self -perpetuating  and  the  duties 
should  be  those  described  in  the  chapter  pertaining  to  this  matter. 

Finances. — As  indicated  in  the  section  on  this  subject,  the 
finances  of  these  institutions  must  be  managed  in  an  absolutely 
business-like  way.  One  element  must  be  carefully  observed  in 
order  to  make  the  continued  usefulness  of  these  institutions  pos- 
sible. The  maintenance  of  every  individual  patient  must  be  paid 
for  by  some  one.  This  may  be  done  by  the  patient  himself,  by  a 
friend,  by  some  church  or  society,  or  by  the  use  of  some  established 
fund;-  but  it  must  be  paid. 

Another  principle  which  must  be  adhered  to  is  thai  the  total 
expenditures  for  the  year  are  kept  within  the  income,  except  in 
case  of  great  emergency.  If  these  two  important  principles  are 
closely  followed,  and  if  the  care  of  patients  is  in  the  bands  of 
competent,  conscientious  physicians  and  surgeons,  these  Lnstitu 
tions  will  be  certain  to  prosper,  while  without  these  it  will  be 
equally  certain  to  fail,  even  though  great  sums  of  money  are  ex- 
pended in  its  maintenance. 

Nursing  Staff. — No  part  of  these  institutions  should  he  better 
organized  than  the  nursing  staffs.  In  the  smaller  ones  the  super- 
intendent of  nurses  may  occupy  the  position  of  superintendent  <>f 
nurses,  matron  and  surgical  nurse,  lu  the  larger  institutions  a 
housekeeper  or  matron  may  be  added,  and  if  the  hospital  contains 


448 


llusi'l  I'AI.S    FOB    TOWNS   OF  ABOUT   5,000   I X  H  A.BITANTS 


more  than  one  hundred  beds  there  should  be  an  assistant  superin- 
tendent who  may  at  the  same  time  serve  in  the  capacity  of  head 
nurse  in  the  surgical  department. 

Buildings.— The  buildings  should  be  attractive,  simple  and 
safe.  It'  more  than  three  stories  in  heighl  thej  must  be  absolutely 
Qreproof.  It'  three  stories  or  less  in  heighl  they  should  be  fire- 
proof when  possible.  When  this  is  not  possible  because  of  local 
reasons,  every  precaution  should  be  taken  to  make  the  building 
safe.  The  broad  halls  should  open  at  each  end  of  the  building 
through  large  doors  upon  broad  verandas.  The  stairs  should  be 
wide  and  easy.     There  should  be  stand  pipes  with  attached  hose; 


HV.I.-NLIT  I 'LA/1  ""■~,0,  * 

A       Col     1  T  I.'Y      HOiPI  \l 

Mixer   J.    Sturm.    Architect. 

fig.  283. 

the  wall-  and  floors  should  be  constructed  as  nearly  fireproof  as 
conditions  permit.  This  is  not  intended  as  a  justification  for  build- 
ing hospitals  which  are  fire  traps,  but  to  suit  conditions  where  it 
is  preferable  to  have  a  non-fireproof  hospital  rather  than  no 
hospital  at  all. 

Figures  283,  284,  285  represent  a  small  country  hospital 
intended  to  serve  later  as  a  home  for  nurses.  At  each  of  the  short 
ends  a  Large  porch  is  to  be  built,  although  it  is  not  shown  in  the 
figures.  It  may  be  built  two  or  three  stories  in  height.  Tn  case 
it  is  two  stories  in  height  the  veranda  is  to  form  a  balcony  on  the 
second  story.  In  case  of  three  stories  there  is  to  be  a  porch  on 
the  second  story  and  a  balcony  on  the  third.    With  two  stories  it 


HOSPITALS   FOR   TOWNS  OF   ABOUT    5,000    INHABITANTS 


4I*> 


will  house  from  eleven  to  fifteen  patients,  with  three  stories. 
twenty-two  to  thirty.  Two  of  the  rooms  are  connected  by  a  pri- 
vate bath  and  toilet  room.  When  changed  into  a  home  for  nurses 
and  servants  it  will  house  fifty-eight  people  if  three  stories  in 
height,  or  thirty-seven  if  two  stories.  Each  of  the  rooms  on  the 
second  and  third  floors,  with  the  exception  of  the  two  located  in 
the  northeast  corner,  are  large  enough  to  serve  as  sleeping  room 
for  two  nurses  or  servants.  On  the  first  floor  the  kitchen,  pantry 
and  dining  rooms  are  to  be  transformed  into  dormitories,  as  these 
departments  are  to  be  placed  in  the  first  story  of  the  hospital 


nnyrn.ooDPLA/1 
A   Comtpy  Hospital 

Meyer   J.    Sturm,    Architect. 

fig.  284. 

building  proper  when  the  original  biiilding  has  become  too  small 
to  house  the  patients.  The  operating  room  may  be  changed  Into 
a  library  or  a  recreation  room  for  nurses.  The  sterilizing  and 
anesthetizing  rooms  may  be  utilized  for  any  purpose  that  condi- 
tions may  indicate.    This  plan  will  serve  as  a  general  example. 

The  hospital  plan  as  designated  in  Figures  286,  287,  288,  289 
may  be  increased  in  size  indefinitely  by  lengthening  the  building 
or  by  adding  any  number  of  stories.  A  few  changes  which  will 
be  indicated  later— will  be  necessary  if  this  building  is  to  be  en- 
larged to  accommodate  two  hundred  or  more  patients.  If  the 
original  building  will  house  between  fifty   and   sixty  nurses  am! 


450 


EOSPITALS   FOB    TOWNS   OF    ABOUT   ."),()(>(>   I.N'HAP.ITAXTS 


servants,  the  new  building  should  be  planned  for  about  one  hun- 
dred patients,  and  in  addition  one  or  two  unfinished  floors  should 
be  provided  to  fill  possible  future  requirements.  In  this  case  it 
would  be  best  to  arrange  the  first  floor  of  the  new  building  to  be 
u^v(\  for  offices,  waiting  rooms,  examining  rooms,  laboratory,  house 
physician's  rooms,  library,  parlor,  office  of  superintendent  of 
nurses,  nurses'  class-room,  and,  if  the  conditions  require,  a  chapel 
thai  should  also  be  placed  on  this  floor.  This  latter  provision  is  a 
very  important  one.  because  it  will  enable  the  friends  of  the  hos- 
pital to  attend  chapel  without  interfering  with  the  comfort  of  the 
patients,  all  of  whom  will  he  above  the  first  floor. 


^I 

blXOHOrLOORPLA/l 

A    COU/1TPY    H05PITAL 

Meyer   J.    Sturm.    Architect. 

fig.  285. 

Another  change  that  would  be  indicated  in  case  the  hospital 
were  eventually  to  provide  for  more  than  one  hundred  patients 
would  be  a  separate  building  for  boiler-room,  coal-room,  power- 
plant  and  laundry.  This  auxiliary  building  can  be  arranged  to 
contain  a  small  department  for  contagious  diseases  which  might 
develop  in  the  hospital,  or  which  might  be  admitted  under  a  mis- 
taken diagnosis,  [f  such  a  department  is  added,  it  should  consist 
of  two  small  wards,  a  nurses'  room,  a  bathroom  and  a  toilet  room. 
By  placing  the  doors  properly  these  three  departments  can  easily 
be  arranged  so  that  they  will  in  no  way  interfere  with  each  other. 
This  building  should  also  contain  the  morgue. 


HOSPITALS  FOR  TOWNS  OF   ABOUT   5,000  INHABITANTS  451 


fig.  286. 

Basement  Plan.    Lucy  Brinkley  Hospital,  Memphis,  Tenn.    Meyer  J.  Sturm.  Architect. 


452  HOSPITALS  FOB    TOWNS   OF    ABOUT   5,<  3<  |l  I    INHABITANTS 


-Q 


li=q R==c 


fig.  287. 

First  Floor  Plan.    Lucj    Brinklej    Hospital,  Memphis,  Tenn.  "Meyer  J.  Sturm.  Architect. 


HOSPITALS  FOR  TOWNS  OF  ABOUT   5,000  INHABITANTS 


453 


This  arrangement  will  allow  for  the  housing  in  the  nurses' 
home,  Figure  283,  284,  285,  a  sufficient  number  of  additional  nurses 


fig.  288. 
Second  Floor  Plan.     Lucy  Brinjdey  Hospital,  Memphis,  Term. 
Meyer   J.    Sturm,    Architect. 

and  servants  to  supply  the  increase* I  del i ta ad.     Ii  (lie  institution  is 
located  in  a  community  whieh  will  eventually  demand  hospital  ac- 


4.)4  hospitals  for  towns  of  about  5,000  inhabitants 


(•oiimiodations  for  two  hundred  or  more  patients,  then  the  orig- 
inal Figure  283,  284,  285  should  be  planned  larger  to  suit  the  condi- 


fig.  28! ». 
Top  Floor  Plan.    Lucy  Brinkley  Hospital,  Memphis,  Tenn.     Meyer  J.  Sturm,  Architect. 

lions.    This  can  be  done  very  readily  by  adding  to  the  Length  of 
the  building. 


HOSPITALS  FOR  TOWNS  OF   ABOUT   5,000   INHABITANTS  455 

In  the  plans  under  discussion  all  of  these  conveniences  have 
been  provided  for  with  the  exception  of  the  department  for  con- 
tagious diseases.  The  building  may  be  entirely  occupied  by  adult 
female  patients,  gynecological  and  obstetrical,  hence  it  is  rela- 
tively easy  to  provide  against  the  admission  to  the  hospital  of  any 
suffering  from  a  contagious  disease.  In  case  an  accident  of  this 
kind  should  occur  the  patient  should  at  once  be  removed  to  com- 
fortable quarters  outside  the  hospital,  and  supplied  with  a  pri- 
vate nurse  to  give  her  the  best  possible  care. 

In  considering  these  plans,  286,  287,  288,  289,  it  should  be  stat- 
ed in  the  beginning  that  this  hospital  represents  an  institution  be- 
longing to  a  class  which  must  predominate  in  all  the  towns  and 
cities  of  this  country,  with  the  exception  possibly  of  a  dozen  of  the 
larger  cities  where  conditions  exist  which  force  them  in  a  separate 
class.  This  hospital  represents  a  type  in  which  a  part,  or  all,  of  the 
money  for  the  purchase  of  the  grounds  and  the  construction  of  the 
building  has  been  given  to  the  trustees  by  philanthropic  persons, 
but  in  which  the  money  for  the  maintenance  of  the  institution  must 
be  provided  by  the  patients  treated,  by  their  friends,  or  some 
church  or  fraternal  society.  It  is  consequently  important  that 
the  institution  be  planned  so  as  to  provide  the  best  possible  care 
at  a  cost  not  to  exceed  an  amount  which  could  be  reasonably  ob- 
tained from  the  sources  mentioned. 

Beginning  with  the  basement,  we  have  a  number  of  depart- 
ments conveniently  arranged  at  a  minimum  expense. 

In  this  institution  the  power  for  running  the  elevator  and 
laundry  machinery  is  secured  from  a  neighboring  electric  plant. 
This  plan  is  desirable  in  many  cities  where  one  can  buy  electricity 
cheaper  than  it  can  be  made  on  the  premises.  Were  it  necessary 
to  manufacture  electricity  for  lighting  and  power,  a  portion  o\ 
the  boiler-room,  near  the  elevator,  could  lie  partitioned  off  for 
this  purpose. 

The  laundry,  ironing  and  sewing  rooms  are  Located  at  the 
extreme  end  of  this  floor,  entirely  separated  from  the  boiler  and 
engine  rooms.  These  rooms  are  especially  well  lighted  and  vent: 
lated.  Tf  desired  a  second  swinging  glass  door  may  be  placed 
just  to  the  north  of  the  elevator  in  order  to  further  Interrupt  any 
slight  noise  from  the  laundry. 

The  general  store  rooms,  locker,  trunk  room,  drug  room,  bath 
and  toilet  rooms  provided  by  this  plan  are  so  evidently  convenient 
that  it  will  not  be  necessary  to  discuss  them  especially.  The  store 
room  at  the  south  end  may  be  utilized  for  a  general  workshop 
for  repairing  furniture,  painting  bedsteads,  making  splints,  mid 
manv  other  things  that  are  constantly  to  be  done  in  an  institution. 


456  HOSPITALS    FOB   TOWNS  OF   ABOU1    5,000  INHABITANTS 

Figure  287  represents  the  first  floor  in  which  one-half  of  the 

total  floor  space  is  utilized  for  administration  purposes,  the  re- 
maining- portion  for  housing  obstetrical  patients  and  infants. 
Were  the  administration  departments  housed  in  the  auxiliary 
building  described  in  Figures  283  to  285,  the  space  for  patients 
would  be  greatly  increased  ruder  the  present  condition  the  room 
labeled  "Trustees"  may  be  used  as  a  general  sitting  room  or  par- 
lor and  library,  except  during  the  few  hours  each  week  when  the 
trustees  meet.  The  hospital  portion  proper  is  separated  from  the 
offices  by  swinging  doors,  so  that  the  patients  are  not  disturbed  by 
people  whose  business  takes  them  to  the  hospital  office.  It  will  be 
noticed  that  the  elevator  is  entirely  separated  from  the  hall  by 
swinging  doors.  Too  much  stress  cannot  be  laid  upon  the  impor- 
tance of  placing  swinging  doors  at  every  point  at  which  a  door  is 
actually  intended  to  separate  departments. 

The  bath  rooms  on  all  the  floors  correspond  in  location  so 
that  but  one  stack  of  plumbing  is  required.  The  diet  kitchen  is 
directly  below  the  general  kitchen,  and  also  corresponds  in  loca- 
tion to  those  on  the  succeeding  floors.  The  diet  kitchens  are  con- 
nected with  the  general  kitchen  by  means  of  a  dumb  waiter,  and 
in  a  six-story  building  food  would  have  to  be  carried  less  than  a 
distance  of  sixty  feet  before  delivering  it  on  the  lowest  floors  for 
distribution. 

Figure  288  represents  one  of  the  intermediate  floors.  It  cor- 
responds exactly  with  the  first  floor  so  far  as  the  location  of  the 
elevator,  the  diet  kitchen,  bath,  toilet  and  service  rooms  are  con- 
cerned. It  will  be  seen  that  the  floor  provides  an  enormous  pro- 
portion of  space  for  occupation  by  the  patients,  compared  to  the 
amount  given  to  service  rooms.  Counting  the  space  occupied  by 
the  elevator,  not  much  more  than  one-fifth  of  the  floor  space  is 
i.iven  to  administration,  which  is  less  than  one-third  of  the  space 
allowed  for  these  purposes  in  many  institutions.  This  serves 
,iot  only  to  lessen  the  cost  of  construction,  but  to  greatly  reduce 
the  running  expenses  of  the  institution.  If  it  is  desired  to  have 
wards  on  one  or  more  of  the  floors,  instead  of  having  only  pri- 
vate rooms,  they  can  he  obtained  by  leaving  out  the  first  and  third 
partition  on  each  side  of  the  elevator  and  the  corresponding  parti- 
tions on  the  west  side  of  the  buiiding.  The  fifteen  private  rooms 
will  then  be  changed  into  seven  four-bed  wards,  and  one  separate 
room,  which  may  be  used  for  one  or  two  beds.  It  would  be  well 
1o  have  a  movable  steel  wire  window  screen  in  this  room,  in  case 
it  should  be  necessary  for  a  delirious  patient. 

It  is  plain  that  the  capacity  of  the  hospital  may  be  increased 
bv  additional   stories,  or  it  may  be  increased   by  lengthening  at 


HOSPITALS  FOK   TOWNS  OF   ABOUT   5,000  INHABITANTS  457 

either  end.  As  has  been  mentioned  before,  it  will  be  necessary  to 
provide  for  an  additional  elevator  if  the  total  capacity  of  the 
building  exceeds  150  or  200  patients. 

Figure  289  represents  the  top  floor,  with  the  operating  de- 
partment at  the  north  end.  The  operating  room  is  provided  with 
very  large  plate  glass  windows  facing  north,  and  with  large  sky- 
lights facing  in  the  same  direction.  The  drawing  shows  east  and 
west  windows  which  are  placed  in  position  to  prevent  the  uu- 
slightly  appearance  of  the  outside  wall.  In  order  to  prevent 
troublesome  shadows  and  the  annoyance  of  sunlight  upon  the 
operation  field,  steel  sliding  curtains  should  be  placed  so  they  can 
be  closed  before  the  preparation  of  the  room  is  begun  on  operat- 
ing days.  After  the  operations  have  been  completed  these  win- 
dows will  serve  to  air  and  sun  the  room. 

The  recovery  room  in  this  plan  is  one  large  room,  as  only 
female  patients  are  treated  in  this  hospital.  Just  south  of  the 
elevator  on  this  floor,  a  partition  with  swinging  doors  should  be 
placed,  which  will  serve  to  separate  the  operating  department 
from  the  kitchen  department.  There  will  be  an  abundance  of  light 
in  the  north  end  from  suitable  skylights  placed  at  this  point.  The 
swinging  doors  have  not  been  shown  on  this  drawing. 

A  second  provision  for  the  separation  of  these  two  depart- 
ments is  in  the  form  of  double  swinging  doors  at  the  entrance  of 
the  anesthetizing  room.  This  room  and  the  sterilizing  room  have 
been  placed  so  that  they  may  be  utilized  with  equal  facility  in  con- 
nection with  both  operating  rooms. 

The  confinement  room  is  on  this  floor  and  is  provided  for 
patients  occupying  private  rooms.  The  toilet  room  on  the  floor 
contains  a  shower  bath  for  the  surgeons,  a  series  of  individual 
lockers,  closets,  slop  hopper  and  sink.  In  a  larger  hospital  two 
rooms  may  be  provided  with  these  conveniences. 

As  stated  before,  this  plan  represents  a  most  satisfactory  hos- 
pital for  the  conditions  for  which  it  is  designed.  It  is  built  entire- 
ly of  stone,  brick  and  reinforced  concrete  and  is  absolutely  lire- 
proof.  Its  cost  is  somewhat  less  than  one  thousand  dollars  for 
each  patient  it  will  accommodate. 

HOSPITALS  IN  SMALL  TOWNS. 

In  connection  with  the  construction  of  very  small  hospitals  in 
towns  which  are  not  large  enough  to  support  an  institution  of 
considerable  size  there  are  many  things  to  be  considered  by  th<' 
community,  as  well  as  by  the  practitioners  who  undertake  to  es 
tablish  such  an  institution.  In  the  first  place,  with  the  introduc- 
tion of  these  small  hospitals  there  follows  the  same  distinct  gain 


1:58 


HOSPITALS   FOR    TOWNS  OF   ABOUT   5,0l)0    I X  11  ABITAXTS 


in  the  care  to  be  obtained  for  cases  which  in  Larger  cities  would 
go  to  hospitals.  Such  patients  arc  compelled  in  tlie  smaller  towns 
to  be  satisfied  with  very  unsatisfactory  home  treatment,  unless 
they  can  assume  the  expense  and  inconvenience  of  transportation 


to  a  city  hospital.  For  example,  a  patient  might  sustain  a  severe 
fracture  al  some  distance  from  home.  A  temporary  dressing  could 
be  applied  by  almosl  anj  <me  at  hand;  the  patient  placed  upon 
an  improvise* I  stretcher,  say  a  cot  bed  or  wire  mattress,  and  on 


HOSPITALS   FOE   TOWNS   OF   ABOUT    5,000    INHABITANTS  £59 


x^ 


■n 

r 

°  ? 


CO 


■N^0_(TH^^ 


S 
2 


460  HOSPITALS    Fill!    TOWNS   OF   ABOUT    5,000   INHABITANTS 

this  transported  to  the  village  hospital  in  a  comfortable  wagon 
to  be  found  on  any  farm.  In  the  hospital  the  patient  would  be 
under  daily  observation  of  the  physician  until  bis  condition  war- 
ranted removal  to  his  home.  All  this  with  vastly  less  labor  on 
the  part  of  the  physician,  and  much  better  care  for  the  patient 
than  could  ordinarily  be  given  in  his  home.  The  same  conditions 
apply  to  all  emergency  cases,  where  immediate  hospital  observa- 
tion is  desirable.  A  strangulated  hernia,  for  instance,  has  a  much 
better  chance  for  recovery  if  taken  immediately  to  a  local  hospital 
and  operated  upon  than  if  conveyed  a  considerable  distance  to  a 
city,  or  if  operated  upon  at  home. 

The  greatest  benefit  to  the  community  and  to  the  local  profes- 
sion comes  from  the  fact  that  the  very  presence  of  a  hospital  in 
the  town  stimulates  at  least  one  of  its  physicians  to  study  and 
improve  his  professional  ability;  this  in  turn  compels  his  com- 
petitors to  do  likewise,  from  the  simple  necessity  of  self-preserva- 
tion. Practitioners  will  thus  form  the  habit  of  reading  the  best 
and  newest  medical  books  and  journals;  they  will  form  medical 
societies  of  their  own,  and  also  attend  the  societies  and  clinics 
held  in  the  medical  centers,  and  there  learn  from  the  masters  in 
the  profession.  Experience  has  shown  that  wherever  a  small  hos- 
pital has  been  established  in  one  of  these  small  towns,  the  ulti- 
mate outcome  has  always  been  for  the  good  of  the  community,  as 
well  as  for  the  physician  in  charge,  and  incidentally  for  all  com- 
petitors. 

At  first  one  or  the  other,  or  all,  of  the  following  unfortunate 
contingencies  may  arise  in  the  management  of  the  hospital,  and 
as  all  of  these  are  in  the  main  avoidable,  it  may  be  well  to  direct 
attention  to  them  at  this  point. 

Instead  of  planning  these  institutions  to  suit  the  conditions 
present  in  the  village,  they  are  often  patterned  after  institutions  in 
the  great  cities,  and  as  a  result  the  running  expenses  will  exceed 
the  income  to  such  an  extent  that  the  institution  will  become  a 
burden  to  its  supporters.  To  overcome  this  difficulty  the  accom- 
panying plans  have  been  arranged.  Figures  290,  291,  292,  293.  It 
will  be  -ecu  that  these  fill  the  conditions  by  their  compactness  and 
their  arrangement,  which  supplies  a  large  amount  of  utility  at 
a  relatively  small  expense.  In  each  instance  the  physician's  office 
with  suitable  waiting  room  and  two  examining  rooms  makes  it 
possible  for  him  to  do  his  daily  office  work  in  the  hospital  build- 
ing, with  the  advantage  of  enabling  him  to  care  for  his  hospital 
patients  at  the  same  time,  without  much  additional  labor,  and  the 
further  advantage  of  making  people  familiar  with  the  institution, 
which  helps  to  overcome  the  prejudice  that  naturally  exists  in  the 


HOSPITALS  FOR  TOWNS  OF  ABOUT   5,000  INHABITANTS  461 

beginning  of  such  an  undertaking.  It  will  be  readily  seen  that 
unless  the  waiting  room  and  the  examining  rooms  are  carefully 
planned  and  placed,  the  arrangement  will  not  be  satisfactory 
either  to  the  physician  or  the  patients.  In  any  given  case  the 
physician  in  charge  of  the  construction  should  study  existing  con- 
ditions carefully,  and  secure  plans  which  have  filled  similar  re- 
quirements satisfactorily  elsewhere. 

Another  source  of  disappointment  comes  from  circumstances 
closely  related  to  those  already  mentioned.  It  occasionally  hap- 
pens that  the  physician  in  charge  of  one  of  these  institutions 
will  undertake  the  treatment  of  cases  requiring  a  degree  of  skill 
far  in  excess  of  his  limited  experience.  This  is  because  of  the 
fact  that  his  early  cases  have  been  simple  and  consequently  suc- 
cessfully treated.  The  good  results  obtained  established  a  local 
reputation;  this  in  turn  brought  the  more  difficult  cases,  which 
had  previously  sought  relief  in  the  larger  medical  centers.  In- 
stead of  stating  plainly  and  frankly  to  the  patient  that  he  does 
not  feel  prepared  to  treat  a  case  of  such  grave  importance,  and 
that  the  patient's  chances  for  recovery  would  be  better  in  more 
skilled  hands,  the  physician  in  question  permits  himself  to  be  per- 
suaded into  doing  that  which  he  knows  he  cannot  do  well.  A  few 
errors  of  this  kind  will  materially  injure  the  future  interests  and 
usefulness  of  both  the  physician  and  the  hospital. 

An  alternative  equally  bad  is  to  keep  the  patient  in  Hie  hos- 
pital and  send  for  a  surgeon  from  some  large  city  to  perform  the 
necessary  operation.  This  is  done  with  the  idea  of  securing  for 
the  hospital  the  income  from  the  patient  and  the  reputation  of 
having  cared  for  the  case.  There  are  two  reasons  why  this  course 
is  not  advantageous  either  to  the  hospital  or  to  the  physician.  The 
surgeon  from  the  city  is  compelled  to  perform  a  difficult  operation 
under  conditions  with  which  he  is  not  accustomed,  with  assistants 
not  familiar  with  his  methods,  consequently  he  will  have  a  lessened 
success,  for  which  the  home  physician  will  in  all  probability  be 
blamed.  On  the  other  hand,  if  the  patient  recovers  the  local 
physician  is  credited  with  being  able  to  do  only  very  simple  opera- 
tions. To  remedy  this  difficulty  the  local  physician  should,  in  case 
he  feels  incompetent  to  treat  a  case,  send  it  to  the  person  he 
considers  most  competent,  explaining  to  the  patient  that  in  a  few 
years,  when  local  conditions  have  become  more  thoroughly  organ- 
ized, he  will  himself  be  able  to  undertake  the  treatmenl  of  sueli 
cases.  This  will  establish  two  facts  first,  that  the  work  done  in 
the  institution  is  by  the  physician  in  charge,  who  is  willing  to  take 
all  blame  for  bad  results  and  who  will  consequently  be  credited 
for  the  good  ones.    Second,  that  he  is  willing  to  bear  the  financial 


462  BOSPITALS  FOR   TOWNS  OF    VBOTJT    5,000    I  X  B  MMT  \  "l's 

P= LMrrn5] 


pig.  292. 

Meyer  J.  Sturm,  Architect. 


HOSPITALS   FOR   TOWNS  OF   ABOUT   5,000    INHABITANTS 


463 


loss  incurred  by  sending  away  patients  who  can  be  better  treated 
elsewhere.  At  first  it  may  seem  as  though  this  could  not  result 
in  prosperity  either  to  the  physician  or  to  the  institution,  but  it 
has  been  tried  and  the  experiment  has  shown  quite  the  opposite  to 
be  true. 

So  far  these  hospitals  have  prospered  only  when  conducted  by 
individuals.     If  built  by  the  community  there  are  then  too  many 


\,n     ,  i'    r*  jm  y.'i    '  '  ■•  *     ■  "    .  - 


r-LrrVATiO/i 
fig.  293. 

interests,  too  many  persons  who  know  nothing  aboul  hospital 
management,  who  will  try  to  have  an  important  hand  in  the  affair. 
An  ideal  arrangement  would  be  a  combination  between  the 
community  and  all  of  the  reputable  physicians  located  in  the  vil- 
lage.   But  local  jealousies  would  probably  make  this  arrangement 


•4-6-1:  HOSPITALS  FOR   TOWNS  OF  ABOUT   5,000  INHABITANTS 

impossible,  although  ultimately  it  may  become  necessary  for  the 
various  physicians  to  work  together  in  a  common  village  hospital, 
or  each  physician  may  be  compelled  to  establish  bis  own  small 
hospital. 

It  is  often  difficult  for  the  village  physician  to  leave  his  hos- 
pital and  go  away  for  the  purpose  of  study.  In  order  to  overcome 
this  the  following  plan  has  been  employed  very  satisfactorily:  In 
the  large  city  hospitals  the  internes  begin  their  service  at  different 
tunes  of  the  year,  some  of  them  entering  the  hospital  as  soon  as 
they  graduate  from  college  and  some  of  them  six  months  later. 
The  young  men  who  wait  six  months  for  their  service  to  begin 
will  often  be  glad  to  employ  this  period  of  waiting  by  substituting 
for  a  country  doctor  while  he  is  away  doing  post-graduate  work. 
This  insures  for  the  physician  a  substitute  with  ability,  and  also 
protects  him  from  the  loss  of  any  of  his  practice,  as  the  substitute 
will  at  the  end  of  the  prescribed  time  return  to  the  city  to  fill  his 
hospital  appointment.  It  is  much  better  to  keep  a  hospital  open 
throughout  the  year  in  this  manner  than  to  close  it  while  the 
physician  in  charge  is  away  on  a  vacation. 

If  the  hospital  is  very  small  it  will  require  but  one  nurse,  and 
she  may  serve  as  office  assistant  when  there  are  no  severe  cases 
under  care.  In  this  way  the  physician  can  afford  to  employ  a  com- 
petent nurse  for  his  institution,  which  will,  of  course,  be  of  great 
benefit  to  it,  and  to  his  practice. 


CHAPTER  XXVI. 

GENERALC0NSIDERAT10N  OF  HOSPITAL  PLANS 

It  has  seemed  best  to  consider  the  accompanying  plans  in  a 
general  way,  in  order  to  make  clear  our  views  as  regards  the  vari- 
ous typical  hospital  conditions  which  we  have  taken  from  different 
parts  of  the  world  preparatory  to  the  publication  of  this  volume. 

These  institutions  will  be  discussed  in  the  order  of  their  con- 
struction, taking  the  oldest  first.  Only  the  institutions  that  are 
typical,  and  that  have  been  looked  upon  as  models,  will  be  con- 
sidered in  the  discussion  at  this  point. 

The  hospital  represented  in  Figure  29-1  was  built  in  Paris  sixty 
years  ago.  When  one  remembers  the  time  of  its  construction  it  is 
difficult  to  imagine  a  more  perfect  plan.  The  capacity  of  the  hos- 
pital was  about  as  large  as  could  be  handled  by  one  administra- 
tion. The  pavilions  were  so  arranged  that  every  ward  and  room 
had  sunlight  at  some  time  of  the  day;  they  were  sufficiently  far 
apart  to  admit  of  the  sunning  of  the  grounds  surrounding  the 
pavilions,  which  prevented  dampness,  and  the  entire  plant  was 
sufficiently  compact  to  make  the  administration  fairly  economical. 
The  building  was  constructed  of  stone  and  brick  and  was  conse- 
quently fireproof  (fireproofing  was  at  that  time  unknown),  'lucre 
were  no  elevators,  but  comfortable  stairs  were  conveniently  locat- 
ed, and  the  building,  though  three  stories  in  height,  was  easily  ac- 
cessible. The  administration  department  and  the  offices  are  in 
the  front  central  portion  of  the  building  lacing  the  street.  The 
amphitheatre  where  clinics  were  held  is  also  in  this  portion  of  the 
building.  At  this  time  there  were  no  street  cars  in  Paris  and  the 
system  of  local  transportation  was  too  imperfect,  and  too  ex- 
pensive, to  be  used  by  the  working  classes,  consequently  it  was 
necessary  to  have  the  building  at  a  poinl  accessible  to  the  laboring 
population  of  the  city.  Moreover,  Paris  was  al  thai  lime  a  walled 
city,  which  made  it  practically  impossible  to  have  a  hospital  located 
in  the  suburbs.  The  central  location  made  it  possible  to  secure 
upon  the  staff  of  the  hospital  members  of  the  medical  faculty  of 
the  University  of  Paris,  and  the  patients  who  went  to  this  institu- 
tion for  treatment  were  certain  to  have  the  care  of  the  most  capa- 
ble men  in  this  great  medical  center.  After  a  thorough  study  of 
the  plan,  and  the  conditions  at  the  time  they  were  made,  one  must 


li  T  T  *  *  "!"•  t tt**M— *  » 


fig.  294. 
laeiboisiereb  hospital,  paris,  1846.    606  beds. 

Administration. — r.  Main  entrance.  2.  Porter.  3.  Business  office.  4.  Physician  in 
charge.     5.    Policlinic.    6.  Bureau  of  directors.     7.  Physician's  room, 

Pavilions— 8.  Library.  9.  Ward.  10.  Sister.  II.  Pantry.  12.  Soiled  linen.  13. 
Dry  room.      14.    Operation   room. 

Service  Buildings — 15,  25.  Stable.  [6.  Wagon  shed.  17.  Lockers.  18.  Sacristy. 
19.  Chapel.  20.  Morgue.  2r.  Female  baths.  22.  Male  baths.  23.  Sisters'  living  quar- 
ters.    24.    Store   room. 

Laundry — 26.   Laundry.     0.7.  Dryer.     28.   Stores. 

Kitchen  Department — 29.   Employe-'   dining  room.     30.   Store   room.     31.   Kitchen. 

Drug  Store— 32.  Assistant  apothecary.  33.  Apothecary.  34.  Drug  More  and  la- 
boratory. 


fig.  295. 

HOSPITAL   RENKIOJ    ON   THE   DAEDANELLES,    L855-56.      2,250    BEDS. 


£68  GENERAL    CONSIDERATfON    OF    HOSPITAL    PLANS 

DESCRIPTION    OF   FIG.  295 

Bi,  r>_\  B3,  Ba.  Pharmacy.  Ci,  C2,  C3.  Ca.  Stores.  1).  Kitchen.  F.  Officers' 
quarters.  <  '•.  Office.  K.  Kitchen.  L.  Laundry.  M.  Residence  of  lady.  X.  Nurse's 
home.  O.  Nurse's  heme.  I'.  Chief  engineer.  Q.  Paymaster.  R  Residence  of  Greek 
workmen.     S.  Residence  of  Greek  workmen.     'I".  Mortuary.     U.  Stables. 

consider  this  one  of  the  most  admirable  great  hospital  plans  in 
the  world. 

One  of  the  oldest  of  these  institutions,  Fig.  295,  has  for  more 
than  half  a  century  been  especially  admired  because  of  its  unique 
location  in  full  view  of  the  ocean  on  two  sides.  It  is  also  remark- 
able because  of  its  size.  The  hospital  was  built  in  L855,  and  has 
a  capacity  for  2,250  beds.  It  is  composed  of  86  distinct  pavilions, 
all  one  story  in  height.  These  pavilions  are  placed  in  three  groups, 
each  of  these  groups  forming  virtually  a  separate  institution,  with 
separate  kitchen,  drug-room  and  storeroom  for  provisions  for 
each.  The  entire  institution  is  formed  on  the  "barracks'"  plan, 
the  climate  permitting  of  this  method  of  construction.  The  dis- 
tances between  the  buildings  are  sufficient  to  expose  all  the  win- 
dows to  the  sunlight,  and  the  conditions  of  the  soil,  as  weli  as  the 
location  of  the  hospital,  are  all  favorable  to  the  best  natural  drain- 
age. A  number  of  small  buildings  made  perfect  isolation  possible 
long  before  the  nature  of  infection  was  known.  For  tropical  coun- 
tries, and  for  countries  subject  to  earthquakes,  this  plan  with  the 
installation  of  modern  plumbing,  and  a  slightly  greater  separa- 
tion of  the  barracks,  would  still  be  considered  very  satisfactory, 
especially  if  cheap  labor  were  available. 

The  advantages  in  this  variety  of  hospital  may  be  briefly 
stated  as  follows:  It  may  be  cheaply  constructed ;  the  inexpensive 
windows  and  doors,  while  they  protect  the  patients  from  the  sun, 
virtually  leave  them  exposed  to  the  open  air  all  day  and  all  night. 
There  is  no  danger  from  lire,  even  with  the  cheapest  wooden  ma- 
terial; the  food  for  patients  consists  chiefly  of  rice  gruel,  or  sim- 
ilar nutrient,  which  can  easily  be  delivered  to  patients  even  though 
the  distances  from  the  kitchens  are  considerable. 

This  plant  would  be  especially  suited  for  municipal  hospitals, 
insane  asylums  or  hospitals  for  consumptives.  Protection  against 
the-,  mosquitoes  and  other  insects  should  be  perfect,  and  the 
plumbing  should,  of  course,  be  carefully  studied.  For  institutions 
i.'i  colder  part-  of  the  world  a  plan  in  any  way  similar  to  this  would 
be  extremely  bad,  except  for  emergencies  as  in  case  of  war,  disas- 
trous fires  in  a  great  city,  or  in  severe  epidemics. 

The  objection-  to  such  a  plant  in  colder  climates  are  as  fol- 
low-: First,  in  whatever  direction  one  placed  the  lines  of  these 
buildings,  there  would  always   result  an  amount   of  shadow  upon 


Zu    S.    507 


4*  ^rJ 


pig.  296. 

EERBERT    HOSPITAL,    NEAR    WOOLWICH,    L859-G4.       658    BEDS. 

1.  Entrance.  2.  Porter.  3.  Waiting  room.  4.  Exam.  room.  5.  Surgery,  b. 
Nurse's  laundry.  7.  Mending  laundry.  8.  (Iran  linen.  9.  Director,  in.  Clerk.  11. 
Chief  physician.  [2.  Registry.  [3.  Captain  of  orderlies.  [4.  Sergeant  Major.  15.  Pa; 
master.  16.  Chief  cook.  17.  Steward  t8.  Clerk,  [9.  1  ihxary.  20.  Librarian.  z\ 
Porter.  22.  Day  room.  23.  Officer's  dwelling.  24.  Ward.  25,  Nurse.  26.  Pantry. 
27.  Washroom.  28.  Elevator.  29.  Dressing  100m.  30.  Bath.  31.  Pharmacy.  32 
Drugs.     33.  Operating  room.    34.  Amphitheater. 


470 


GENERAL    CONSIDERATION    OF    HOSPITAL    PLANS 


•^.S&s 


^  «    4-d 


fie  G-lE 


£2 


%      ttCt6_, 


• 


■;* 


yVj;*.'  fej  v  Jp 


1 


UUUUUUIT 

IflQiiHinnnpn. 


m. 


«su- 


-nnrnnnrrinnn 


j  p  pun 


CM 

d 


1|gs 

c  *^     .  o 

r    -  io  n 

U   g   H 

X 

U  J;  § 

*-j    c 

p3 

S    tjl    y 

O          ,fi  JO 

0            ti   '"- 

X 

c    &  o.  t 

" 

'■C    rt  ^    rt 

3  -    ''   £ 

•^        _j. - — i 

,— 

m  00    -  '   . 

l>- 

C                   G1- 

3 

^   £   B 

X 

*§8g 

T— 

.   -    ~  £ 

?^ 

— '  '-     c  *"' 

o 

g   y-  t!  °o 

p 

>l£l 

J 

'^  £?  2 

3J 

5" "  .iJ   OT 

e   b  t3  ~° 

HI 

U  >  JcS     u 
>    m    3 

OD 

">           i-  £ 

w 

X 

O    ui    — 

<] 

s 

.5          w 

_t"     O      •  '■£ 

V«   o  o 

H 

.«    p,  > 

t/>              D  VC 

Cj 

>■    i_    ~      — 

/. 

PL,    «+■> 

r-         0         G 

N     C     «     O 

«     O            O 

-   O       •    >- 

-   ■-   5   « 

«  2  ~u 

u    c    u 

GENERAL    CONSIDERATION    OF    HOSPITAL    PLAN'S  4i"l 

the  surrounding  buildings  sufficient  to  cause  a  harmful  degree  of 
dampness.  In  order  to  fully  appreciate  this  statement  it  will  In- 
well  to  refer  to  Atkinson's  Diagram  of  Shadows,  Figs.  9  to  20. 
Second,  the  cost  of  construction  would  be  extremely  high,  because 
of  the  necessity  of  making  the  walls  proof  against  cold  and  winds. 
Third,  the  amount  of  room  exposure  would  be  enormous.  Fourth, 
the  expense  of  heating  such  a  plant  would  be  excessive.  Fifth,  it 
would  be  practically  impossible  to  deliver  food  palatable  and  hot  to 
the  distant  pavilions.  Sixth,  the  cost  of  keeping  the  long  corridors 
clean  would  be  very  great.  Seventh,  all  of  the  patients  would  be 
located  near  the  ground  where  the  air  is  dampest,  and  Least  hy- 
gienic. Therefore,  the  general  idea  represented  in  this  plan  may 
be  recommended  for  tropical  countries,  earthquake  regions  or  the 
dry  plains  of  the  southwest  portions  of  the  United  States. 

The  next  great  hospital  (Fig.  296)  in  time  of  construction,  is 
the  Herbert  Hospital,  near  Woolwich,  built  in  1S59-64,  and  planned 
to  contain  658  beds.  A  glance  at  the  ground  plan  of  this  institu- 
tion shows  that  its  construction  was  carefully  determined  as  re- 
gards sunlight  and  natural  ventilation.  The  choice  of  location 
outside  the  city,  upon  an  elevation,  is  most  admirable.  The  build- 
ing is  constructed  with  a  high  basement,  and  two  stories  above, 
producing  conditions  which  were  quite  ideal  before  the  time  of 
fireproofing  and  elevators.  The  buildings  are  connected  with  a 
central  corridor,  which  is  but  one  story  in  height,  in  order  to  pre- 
vent unnecessary  shadows  upon  the  ground.  The  pavilions  arc 
far  enough  apart  to  allow  of  the  perfect  sunning  of  the  grounds, 
and  still  near  enough  together  to  permit  a  relatively  economical 
administration  for  an  institution  of  this  type.  For  municipal  hos- 
pitals, occupied  largely  by  factory  employes  who  do  not  object 
to  large  wards,  such  a  plan  must  be  looked  upon  with  great  ad- 
miration, considering  the  time  of  its  construction. 

Because  of  its  location  on  the  banks  of  the  River  Thames,  op- 
posite the  House  of  Parliament,  Figure  297,  represents  the  best 
known  hospital  ever  built  upon  the  several  storied  pavilion  plan. 
Aside  from  these  features  it  is  remarkable  for  its  great  architec- 
tural beauty.  The  pavilions  are  a  sufficient  distance  apart  to  in- 
sure an  abundance  of  air  and  sunlight ;  they  arc  all  connected  by 
corridors;  the  bath  rooms  are  at  one  extreme  of  the  pavilion,  al 
the  other  end  are  isolation  rooms,  nurses  and  service  rooms,  and 
consultation  rooms.  Considering  the  time  when  it  was  built,  the 
plan  must  be  looked  upon  as  practically  perfect.  Under  present 
conditions,  with  the  possibility  of  easy  and  comfortable  transpor- 
tation, it  is  likely  that  better  plans  from  an  economical  as  well 
as  hygienic  standpoint,  could  be  made.     An  ideal  institution  would 


472 


GENERAL   CONSIDERATION    OF    HOSPITAL   PLANS 


be  one  of  this  kind  placed  upon  an  elevated  portion  of  land  within 
ten  miles  of  the  city  limits.  It  could  be  easily  reached  by  automo- 
bile ambulance,  or  ambulance  cars,  which  could  be  run  from  a 
central  receiving  hospital,  making  as  many  trips  each  day  as  would 
be  required  to  carry  the  day's  accumulation.  This  would  trans- 
port  the  patients  out  of  the  smoke-laden  city  atmosphere.     The 


...,,....  i , 


fig.  298. 

GENERAL  CITY   EOSPITAL  AT  FRIEDRICHSHAIN,  BERLIN,  L868-74.  G24  BEDS. 

i.  Administration  2,  3,  4.  5.  Hospital  buildings.  6.  Management.  7.  Boiler  house. 
8,  Porter's  lodge.  9.  Nurse's  home.  10.  Disinfection.  11.  [cehouse.  12.  Mortuary. 
[3,  Drying  place.  [4.  Officer's  garden.  15.  Chapel.  16.  Operating  building.  17.  Bath- 
house. 

6.  Pavilions  for  medical  patients.  4.  Pavilions  for  surgical  patients.  2.  Pavilions 
for  contagious  patients.     Double  pavilions  for  diphtheria. 

land  occupied  by  the  presenl  building  if  sold  would  bring  a  suffi- 
cient sum  of  money  not,  only  to  construct  a  new  hospital,  but 
enough  furthermore  to  support  such  an  institution  for  an  indefi- 


GENERAL   CONSIDERATION    OF    HOSPITAL    PLANS  ±7o 

nite  period,  if  invested  in  proper  securities.  No  doubt  such  plans 
will  ultimately  materialize,  but  for  a  centrally  located  institution, 
the  general  idea  of  this  hospital  must  continue  to  stand  as  an  ex- 
cellent model. 

The  hospital  shown  in  Fig.  298  was  built  just  before  the  anti- 
septic period.  At  that  time  there  existed  a  general  feeling  among 
scientific  medical  men  that  a  definite  substance  passed  from 
one  patient  to  another,  causing  the  second  patient  to  become 
afflicted  with  the  same  disease  as  the  first ;  an  affection  thai  would 
attack  patients  successively  in  one  building,  hut  would  not  affect 
those  in  a  separate  building.  Pasteur  was  hard  at  work  at  this 
time  laying  the  foundation  for  our  present  knowledge  concerning 
infection  and  contagion,  but  everywhere  the  practical  subject  of 
isolation  was  becoming  recognized.  In  order  to  secure  the  great- 
est amount  of  isolation,  and  still  attain  as  perfect  hygienic  condi- 
tions as  possible,  this  hospital  was  built  as  illustrated  in  Fig.  "JDS. 

The  buildings  were  scattered  in  a  beautiful  park  as  far  apart 
from  each  other  as  the  available  amount  of  space  would  allow. 
They  were  screened  from  the  surrounding  streets  by  intervening 
shrubbery.  The  buildings  were  all  independent,  Ioav  pavilions. 
illustrated  in  Figures  296  and  297.  In  the  light  of  modern  achieve- 
ments, the  objections  stated  in  discussing  the  plan  in  Figure  295  all 
hold  good  here.  A  compact  building  six  or  more  stories  in  height 
could  be  constructed  for  a  little  more  than  one-half  the  cost  of  this 
institution,  and  it  could  be  maintained  at  an  expense  of  approxi- 
mately 60  per  cent,  of  the  running  expenses  oi  a  building  upon 
the  plan  298.  It  must  be  remembered,  however,  that  this  building 
was  constructed  before  the  era  of  fireproofing,  before  the  introduc- 
tion of  elevators  and  before  the  cause  of  infectious  and  contagious 
diseases  had  been  discovered.  It  was  not  then  known  that  the  air 
in  the  sixth  story  of  a  building  contains  fewer  micro-organisms 
than  that  of  the  first  story.  With  the  knowledge  available  at  the 
time  this  hospital  was  constructed,  nearly  forty  years  ago,  one 
must  consider  it  a  remarkable  production. 

Compared  with  the  hospital  just  described,  that  illustrated  in 
Fig.  299  is  an  unsatisfactory  example  of  a  similar  system.  There 
is  much  greater  concentration  with  the  resulting  convenience  in 
management.  All  of  the  pavilions  are  arranged  so  they  can  he 
easily  reached  from  the  corridor  which  passes  along  one  end  of 
each  pavilion,  with  the  exception  of  four  pavilions  in  the  semi- 
circle. At  the  north  end  of  the  building  all  the  pavilions  extend 
from  east  to  west,  thus  exposing  one  side  to  the  sun  during  the 
the  entire  time  from  8  a.  m.  to  4  p.  in.  during  the  whole  year,  and 
exposing    the    ends     either    to     the     morning     sun     from     8     a. 


4(4  GENERAL   CONSIDERATION    OF    HOSPITAL   PLANS 

m.  until  12  m.,  or  the  afternon  sun  from  12  until  4  p.  m. 
The  fact  that  one  entire  long  side  of  the  building  receives  no  sun- 
light whatever  during  six  months  in  the  year  is  not  so  great  an 
objection  as  might  be  supposed,  because  the  entire  building,  with 
the  exception  of  the  end  portion,  composes  an  open  ward  which 
is  consequently  sufficiently  sunned  from  the  windows  on  the  south 
side.  The  objection  against  extending  a  building  from  east  to 
west,  with  a  central  corridor  with  rooms  and  wards  on  either  side, 
is.  of  course,  aol  valid  when  applied  to  one  in  which  the  entire 
space  is  given  to  one  la  rue  ward. 

From  a  standpoint  of  economy  of  conduct  this  form  of  con- 
struction is  better  than  that  of  the  hospital  illustrated  in  Figure 
298. 

There  is  another  and  perhaps  more  serious  objection  to  this 
plan.  The  pavilions  are  all  a  short  distance  from  the  street;  they 
are  exposed  to  the  street  noises  and  the  street  dust;  and  the  pa- 
tients are  compelled  to  breathe  this  unwholesome  air.  If  this  in- 
stitution were  an  eight  or  ten  storied  building,  placed  in  the  middle 
of  the  plot  of  land,  every  room  and  ward  would  have  a  view  of 
the  beautiful  Thiergarten,  the  trees  and  shrubbery,  and  the  pa- 
tients could  live  in  an  atmosphere  free  from  dust,  away  from  the 
noise  of  the  street,  with  all  conditions  far  superior  to  those  in 
which  they  now  exist. 

Of  all  American  hospitals  the  Johns  Hopkins  has  received 
most  attention  as  a  model,  because  of  the  study  which  was  given 
preparatory  to  the  completion  of  its  plans.  These  preparatory 
studies  were  incorporated  in  a  collection  of  essays  which  have 
served  as  a  guide  to  American  architects  for  a  period  of  nearly 
thirty  years.  At  the  time  the  plans  were  drawn  they  were  as  per- 
fect as  it  was  possible  to  make  such  plans  with  all  the  available 
facts.  The  location  of  the  hospital  on  high  land  is  ideal:  the 
amount  of  land  ample;  the  spacing  for  air  and  sunlight  perfect. 
At  a  time  when  facts  concerning  infection  and  contagion  were  but 
little  known;  when  there  was  no  hreproohng,  no  elevators;  when 
nothing  was  known  concerning  the  difference  in  the  condition  of 
the  nil-  at  various  elevations;  and  before  any  attention  had  been 
directed  toward  the  dangerous  effects  of  street  dust,  it  is  difficult 
to  imagine  a  more  perfect  scheme. 

At  the  present  lime  the  expense  of  cleaning,  heating,  lighting 
and  keeping  in  repair  a  building  constructed  in  this  way,  would  be 
at  least  40  per  cent,  more  than  in  a  single  many-storied  building, 
with  a  separate  building  for  the  boilers,  electric  power,  mortuary, 
laundry  and  one  for  nurse-  and  employes,  and  another  for  con- 
tagious diseases.    The  high  location  of  this  building  makes  the  fact 


A  Co       ccccccocccc 


S    t    i  s 


n  i   Strom-Strasse 


img.  299. 
city  hospital  in   moabit,  berlin".     811  beds. 

i,  2i.  Porter's  Lodge,  .;.  Administration  building.  .*.  Kitchen.  4.  *3>  *4-  Shed. 
5.  Icehouse.  6.  Department  for  protection  against  lire  7.  Machine  house.  8,  16. 
Disinfection  houses.  9.  Laundry  building.  10.  11.  Patients'  buildings  12.  Workshops. 
15.  Boiler  house.  17.  Stable  for  animals  for  experimenting.  18.  Mortuary.  19.  Out- 
house.    20.   Scales. 


476 


GENERAL   CONSIDERATION    OF    HOSPITAL   PLANS 


~allu. 


-i i 1 1 


FIG.   300. 
JOHNS   HOPKINS    HOSPITAL,  1876.      378   BEDS. 


GENERAL    CONSIDERATION    OF    HOSPITAL   PLANS  4<  / 


DESCRIPTION   OF  FIG.   300 

I.  Administration — I.  Office.  2.  Director.  3.  Waiting,  exam,  and  matron.  4.  Re- 
ceiving room.     5.   Superintendent  nurses.     6.  Library.     7.   Superintendent. 

II.  *..*..*..*..*..*..  9.  Dressing  room.  10.  Kitchen.  11.  Clean  linen.  12.  Bath- 
room.     13.    Elevator. 

III.  Kitchen — 14.  Kitchen.     15.  Pantry.     16.  Storeroom.     17.  Dining  room. 

IV.  Nurses'  Home — 18.  Parlor.  19.  Library.  20.  Head  nurse.  21.  Superin- 
tendent of  nurses. 

V.  Drug  House — 23.  Pharmacy.     24-  Druggist.     25.  Dining  room.     26.  Tea  room. 
VI.,   VII.      Patients'   buildings — 27.    Dining   room.      28.    Pantry.      29.    Clean    limn 

30.   Patients'  clothing. 

VIII.  Isolation  Building — 31.   Nurses'  room. 

IX.  Operating  Building — ^2.  Amphitheater.  ^.  Operating  room.  34.  Physician-' 
room.  35.  Recovery  room.  36.  Nurses.  t,j.  Isolation  room.  38.  Admission  of  in- 
jured     39.    Anaesthetizing   room.     40.   Gynecological   room. 

X.  Policlinic — 41.  Porter.    42.  Nurses'  room.    43.  Diseases  of  throat.    4.;.  Dis 

of  children.    45.  Internal  diseases.    46.  Venereal  diseases.     47.  Dermatological  diseases. 
48.   Neurological  diseases.     49.   Eye  and   ear   diseases. 

XI.  Pathological  Institute — 50.  Amphitheater.  31.  Mortuary.  ^,2.  Bacteriological 
institute.     53.   Examination.     54.    Waiting   room,   library. 

XII.  Laundry — 55.  Patients'  laundry.  56.  Officers'  laundry.  ^,7.  Ironing  room. 
58.  Drving  room.     59.  Drying  room  for  officers  laundry.     60.  Repair  of  bedding. 

XIII.  Chapel. 

XIV.  Bathhouse. 

XV.  Conservatorv  for   Plants. 


ill 


nyinnr_«  .1 


■TinntiuiroiY 


JO- 

A 


fig.  301. 
gattsthaus  btuivetjberg,  antwkiil'.  1  s78.    388  beds. 


GENERAL    CONSIDERATION    OF    HOSPITAL   PLANS  479 

DESCRIPTION  OF  FIG.  301 
A.  Patients'  pavilion.  B,  C.  Accessories.  D.  Private  wards.  E.  Chapel.  G.  Oper- 
ating house.  H.  Administration.  J.  Boilerhouse  and  steam  laundry.  K.  Baths.  L. 
Sisters'  home.  L.  Drug  room  and  kitchen.  M.  Mortuary.  N.  Stables,  e,  e.  Ventilator. 
x,  x.  Ventilator  shaft,  y.  Forced  ventilator  shaft,  z.  Steam  and  condensed  water 
tubing. 

that  most  of  the  patients  are  housed  in  the  first  story  less  objec- 
tionable than  it  would  be  were  the  buildings  not  elevated  above 
the  surrounding  structure. 

About  the  time  that  the  last  mentioned  hospital  was  being 
planned  a  very  unique  institution  was  undertaken  in  Antwerp,  as 
illustrated  in  Figure  301,  the  idea  being  to  supply  an  institution  ir 
which  all  of  the  wards  formed  perfect  circles.  •  These  pavilions  are 
connected  with  the  central  administration  building,  with  the 
kitchen,  mortuary,  bath,  toilet  and  operating  pavilion  by  means 
of  corridors.  The  objection  here  lies  in  the  expense  of  keeping 
clean  and  in  repair  the  great  amount  of  wall  space,  floor  space  and 
windows,  as  well  as  in  heating  the  unused  surfaces  which  are  ex- 
posed to  the  weather.  Another  serious  objection  is  that  the  food 
must  be  transported  such  long  distances  before  it  can  be  delivered 
to  the  patients.  In  a  tropical  country,  with  cheap  service  and 
cheap,  simple  food,  this  plan  might  be  considered  ideal,  but  in  the 
cold  climate  of  Antwerp  it  would  not  at  the  present  time  be  rea- 
sonable to  construct  such  a  building. 

This  is  the  last  plan  (Fig.  303)  to  be  described  of  a  hospital 
built  in  the  pre-antiseptic  period.  From  the  standpoint  of  hygiene  it 
is  undoubtedly  correct.  No  matter  in  which  direction  the  build- 
ing might  be  placed,  the  central  ward  will  receive  an  abundance  of 
light  from  the  south  side.  If  the  building  extends  from  north  to 
south,  one  side  of  the  ward  is  flooded  with  sunlight  during  the 
morning  hours,  and  the  other  side  in  the  afternoon.  The  feature 
which  seems  entirely  unreasonable  is  that  for  a  ward  containing 
sixteen  patients  two  pavilions  should  be  sacrificed  for  operating 
purposes.  Aside  from  this,  the  lighting  of  the  operating  pavilion 
is  remarkably  bad.  This  plan  would  be  most  excellenl  if  the 
building  were  situated  with  its  long  axis  from  north  to  smith,  and 
the  northern  end  utilized  for  an  operating  pavilion,  which  would 
be  lighted  entirety  from  the  north  side.  The  portion  of  this  end 
marked  2  and  4  could  he  changed  into  a  recovery  ward,  and  tin- 
portion  marked  1  in  the  opposite  wing  into  a  <l;i\  room  for  pa- 
tients just  recovering  from  an  operation,  so  they  would  not  disturb 
the  patients  in  the  general  ward.  This  would  also  enable  the  pa- 
tients who  are  convalescent  to  amuse,  themselves  comfortably 
without  disturbing  the  others. 

The  hospital  illustrated  in  Figure  304  is  the  first  greal  hos- 


4SU 


GENERAL    CONSIDERATION    OF    HOSPITAL   PLAN'S 


pital  constructed  after  the  introduction  of  antiseptic  methods.     It 
was  patterned  after  the  hospital  illustrated  in  298. 

This  hospital  has  been  looked  upon  as  a  model  type  of  a  small- 
pavilion  hospital.    It  contains  eighty-two  distinct  buildings,  most 


of  which  are  one  story  in  height,  the  others  two  stories.  The  plant 
occupies  twenty-three  acres  of  land,  and  still  the  amount  of  space 
around  the  buildings  is  not  sufficient  to  prevent  the  shadows  from 
the  various  buildings,  together  with  the  shrubbery,  from  keeping 
the  ground  too  damp  for  satisfactory  hygienic  conditions. 

All  of  the  objections  mentioned  in  reference  to  a  hospital  con- 
structed according  to  Figure  298  would  be  valid  here.     The  dis- 


GENERAL   CONSIDERATION    OF    HOSPITAL    PLANS 


481 


tances  that  liave  to  be  traversed  in  order  to  visit  the  patients  in 
the  various  pavilions  is  so  groat  that  the  chiefs  of  the  departments 
rarely  find  time  to  make  rounds  in  the  wards,  this  duty  being  rele- 
gated to  assistants. 

With  the  present  existing  conditions  in   Hamburg  this  hos- 
pital could  be  constructed  with  a  vast  amount  of  saving,  both  as 


o 

•o 

n> 

"i 

p: 

7Q 

g 

-1 

O 

d 
9 

u 

h- 1 

3 

o 

N 

> 

3 

M 

-H 

o 

dl. 

CO 

n 

^ 

> 

r1 

hrj 

2 

P 

3 

o 

CO 

C/5 

PH 

o 

tzj 

CO 

4- 

^ 

tO 

50 

~ 

1— ' 

<J\ 

■30 
00 

o 

H 

o 

r-1 

n" 

Oi 

r* 

w 

p\ 

73 

regards  construction  and  management,  if  one  or  the  oilier  o\  two 
plans  were  followed.  The  old  general  hospital  is  located  on  a 
piece  of  land  containing  several  acres,  situated  on  I  he  hank  of  ;i 
beautiful  lake  known  as  the  "Alster  Basin,"  within  a  mile  of  the 
business  portion  of  the  city,  and  on  the  od^v  of  the  residence  por- 
tion, an  absolutely  ideal  position.     Had  a  ten-story  building  been 


182  GENERAL   CONSIDERATION    OE    HOSPITAL   PLANS 

constructed,  in  which  the  first  floor  could  be  arranged  for  admin- 
istration rooms,  examining  and  receiving  rooms,  rooms  for  the 
resident  staff,  laboratories  and  pharmacy,  the  top  story  for  oper- 
ating rooms,  dressing  rooms,  recovery  rooms,  kitchen  and  store- 
room, the  remaining  stories  for  housing  two  hundred  patients  on 
each  floor,  the  same  capacity  could  have  been  secured,  with  better 
hygienic  conditions  for  the  patients.  The  cost  of  maintenance  of 
such  an  institution  would  also  be  much  less. 

The  second  plan  for  similar  conditions  would  consist  in  utiliz- 
ing the  plot  of  ground  now  occupied  by  placing  a  many-storied 
building  in  the  middle  of  the  grounds,  and  having  the  surround- 
ing grounds  laid  out  in  the  form  of  a  park,  being  careful  not  to 
plant  trees  near  enough  to  the  buildings  to  cause  an  undue  amount 
of  moisture.  This  again  would  result  in  a  building,  and  a  build- 
ing spot,  of  great  beauty,  and  the  conditions  would  favor  a  great 
saving  both  as  regards  management  and  construction. 

The  hospital  shown  in  Fig.  305  was  designed  with  a  view  to  its 
!'u!  m<'  enlargement,  as  indicated  by  the  dotted  lines.  This  enlarge- 
ment if  made  would  almost  double  the  capacity  of  the  original 
building. 

At  the  time  these  plans  were  made  none  of  the  micro-organ- 
isms producing  contagious  or  infectious  diseases  had  been  posi- 
tively identified,  although  the  cause  of  pus  infection  and  its  pre- 
vention had  already  been  published  by  Sir  Joseph  Lister,  but  the 
theory  of  contagion  was  very  vague.  This  probably  accounts  for 
the  great  area  over  which  so  small  a  hospital  was  distributed.  For 
the  time  of  its  construction  it  should  be  considered  one  of  the  best 
models. 

Pigs.  306,  307  are  the  first  to  show  a  tendency  toward  concen- 
tration, but  a  glance  at  the  amount  of  outside  wall  and  hall  space 
shows  it  to  be  enormous  for  the  very  small  amount  of  utility.  The 
total  amount  of  space  used  for  housing  patients  is  less  than  one- 
third  of  the  entire  tloor  space  in  the  building. 

Figure  308  is  given  as  a  beautiful  example  of  a  children's  hos- 
pital built  after  the  pavilion  plan.  There  is  one  large  pavilion  for 
general  diseases,  a  small  pavilion  for  each  one  of  the  various  con- 
tagions diseases.  Aside  from  these  there  are  separate  buildings 
for  teaching  purposes,  for  examination  and  treatment  of  out- 
patients,  a  boiler  house  containing  the  laundry,  sterilizing  plant. 
and  the  mortuary. 

This  building  contains  the  element  of  concentration,  which 
aids  greatly  in  making  its  maintenance  inexpensive.  The  amount 
of  space  for  air  and  sunlight  is  ample.  There  is  a  distinct  objec- 
tion in  having  wards  as  large  as  are  shown  in  this  plan.    A  second 


GENERAL   CONSIDERATION    OF    HOSPITAL   PLANS 


4s; 


fig.  304. 

THE  NEW  GENERAL  HOSPITAL,  HAMBURG,  EPPENDORF,    L8S4.      1,-17-1-  BEDS. 

B.   II.  Bath  house.     D.  H.  House  for  delirious.     D.  W.   House  for  director.     E. 
II.    Ice    house.     J.    W.,    W.    W.,    Officers'    houses.     K.    G.    Kitchen.     K.   II    Boiler 
house.     I-.    II.   Mortuary.     O.   G.    Management.     ( >.    II.   Operations.     S.    Wareho 
V.  G.   Administration.     V.   W.    Residence  of  administrator.     \Y    II.    Laundry     i — 45. 
47.  Patients'  pavilion.  i 

Contagious  Department — 46,  48—53,  55  u.  II.   Patients'  buildings.     D.  A.  Disinfec 
tion.     P.  K.  Kitchen.     P.  I..  Mortuary.     P.  V.  Administration. 

6.  Receiving  pavilion.  24.  Pavilion-.  4.  Boarders,  i.  e.,  private  patients.  2.  Pavil- 
ions for  eye  cases.  2.  Pavilions  for  children.  1.  Pavilions  for  insane.  5.  Pavilions  for 
isolation.     11.  Isolation  Mocks.    5.  Wooden  barracks, 


4S4  GENERAL   CONSIDERATION    OF    HOSPITAL   PLANS 

objection  lies  in  the  fact  that  the  entrance  to  the  woman's  ward  is- 
through  the  children's  ward. 

Fig-.  .'511  is  the  latest  hospital  which  has  been  completed  on  the 
low  pavilion  plan.  The  genera]  construction  of  most  of  the  pa- 
vilions is  front]  north  to  south,  and  the  general  plan  of  each  pa- 
vilion is  shown  in  Figure  31 1.  The  amount  of  space  utilized  for  the 
propci-  housing  of  patients  in  this  institution  is  very  small  as  com- 
pared to  the  amount  of  floor  space  in  each  pavilion.  The  entire 
plant  is  as  complete  in  every  detail  as  it  can  be  made.  It  covers  an 
area  of  more  than  twenty  acres  of  land;  the  cost  of  constructing 
the  buildings  is  not  great,  when  compared  to  the  number  of  pa- 
tients that  can  be  housed.  Although  this  plant  is  greatly  scattered, 
the  expense  of  maintaining  it  is  not  abnormally  large.  The  con- 
struction was  not  begun  until  1900,  but  the  general  outlines  of  the 
plan  were  established  more  than  twenty-five  years  before  that  time,. 
which  accounts  for  some  of  its  characteristic  features.  It  is  said 
to  be  by  far  the  finest  example  of  an  institution  ever  built  upon 
the  small  pavilion  plan.  It  is  located  in  the  outskirts  of  the  great 
city. 

Fig.  312  shows  a  typical  hospital  for  contagious  diseases  with 
the  high  and  low  pavilion  system. 

There  are  four  pavilions,  three  of  which  aj-e  utilized  for  wards 
for  different  diseases,  and  the  fourth  one  for  an  administration 
pavilion  containing  three  rooms  for  patients  who  are  to  be  kept 
under  observation  in  case  of  doubt  regarding  their  diagnosis 
before  placing  them  in  the  proper  ward.  Were  it  necessary  to 
place  a  definite  distance  between  wards  containing  contagious  dis- 
eases  the  plan  Figure  312  would  be  almost  ideal,  because  of  the 
distance  between  the  various  buildings,  although  not  sufficient  to 
make  the  administration  cumbersome.  The  most  expensive  part 
of  the  administration  would  be  due  to  the  care  required  in  serving 
hot,  palatable  food  to  the  patients,  and  to  the  work  of  keeping 
these  long  connecting  corridors  clean. 

Since  we  know  that  contagion  is  transmitted  by  some  form 
of  contact  only,  except  when  the  number  of  patients  is  so  great 
that  the  air  of  a  room  is  saturated  with  contagions  material,  it 
seems  wise  to  choose  another  form  of  construction,  which  will  be 
considered  later  in  the  discussion  of  the  plan  illustrated  in  Figures 
313,  314,  315. 

THE   MANY-STOKIED  CONTAGIOT  S  HOSPITAL. 

Fig.  31.")  represents  a  typical,  many-storied  hospital  for  con- 
tagions diseases,  together  with  an  annex  containing  the  heating 
plant,  dynamos  for  electric  light  and  power,  the  Laundry  and  the 


GKXKRAL    COXSIDKKATIOX    OF     HOSPITAL    PLANS 


4^:» 


'H7P 


=11.   c 

1= 


hWhh*- 


•  r 


pig.  305. 

CITY    HOSPITAL    FOR    CONTAGIOUS    DISEASES    AT     X  K\V(   \S  II  .1'- C  l'(  i\    :v  \  i'. 

1884.     84  BEDS. 


486 


GENERAL   CONSIDERATION    OF    HOSPITAL   PLANS 


DESCRIPTION  OF  FIG.   305 
[.     Porter's  Lodge— i.  Waiting  room.     2.   Living  room.     3.  Kitchen. 

II.  Administration— 4.  Office.  5.  Physician.  6.  Matron.  7.  Sewing  room.  8. 
Pharmacy,  o.  Patients'  laundry.  10.  General  laundry.  11.  Dining  room  for  nurses. 
12.  Store-.  [3.  Kitchen.  14.  Butler's  pantry.  15.  Pantry.  16.  Polishing  room.  IJ. 
Milk   refrigerator. 

III.  Patient-'    Pavilion— iX.    Ward.      19.    Nurse.     20.    Service    room.     21.    Waiting 


IV.  Laundry — 22 — 24.   Officers'   laundry. 

V.  Laundry— 25.   26.    Patient-'   laundry. 

VI       Disinfection— 27.    Entrance.     2S.    Exit. 
VII.      Stable-. 

Division  of   Patients — Six  pavilions  with  fourteen  beds  each,  total  84;  extension, 
dx  pavilions  with  eight  bed-  each,  total  4^:  grand  total,  132. 


fig.  306. 

First   Floor  Plan.     Hospital  at  Dessau,  \> 


GENERAL   CONSIDERATION    OF    ElOSPITAL   PLANS 


*87 


sleeping  rooms  for  the  servants.  The  object  of  having  a  separate 
building  for  these  departments  is  practically  to  provide  quarters 
for  the  servants  who  work  in  the  hospital  proper.  Unless  such 
quarters  are  provided  it  would  be  difficult  to  secure  servants,  and 
there  would  always  be  the  danger  of  their  carrying  infection  from 


n 


in 


(P 


*T| 


- 

o 

z 

(fl 

CO 

o 

pa 

-~4 

D 


Ki 


&     0 


H 


^3 

x  H 


2 

i 

m           , 

2 

■*  1 

-i  f 

x  L 

n  1 
s  1 

> 

ol 

Mi 

fog 

J      3> 
1      v£      1 

H 

-< 

one  part  of  the  building  to  the  other.  Each  floor  should  be  pro- 
vided with  the  means  to  thoroughly  disinfect  everything  thai  is 
used  by  the  patient,  so  that  nothing  is  returned  to  the  annex  thai 
has  not  been  thoroughly  disinfected;  moreover  all  the  dishes  and 
cooking  utensils  are  returned  in  sterilized  metal  baskets,  and  all 
of  the  linen  is  returned  in  sterilized  canvas  bags. 


488 


(il.XKRAL    CONSIDERATION    OF    HOSPITAL   PLANS 


The  first  floor  is  used  for  the  departments  of  administration, 
and  contains  the  offices,  dining  room  for  nurses  and  physicians, 
dining  room  for  servants,  matron's  room,  examining  rooms,  oper- 
ating  rooms   and    laboratory.      The   direction   of  the   building  is 


'■a .      ti       °P 


Ji         ~         CO 


U 


CI 


oO 


X  3  x 

r-  W  0 

x  5  £ 

M  <  "S 


Q   1 

.    o 

in   v- 


x    5 


_2    "i 


■5  o* 


co  co 


o   c 

o    >- 


E     e  M-J     3 


"t    -     -       . 


B    _;   cd    >t 

«    fi    =  ' 

i-J    o 


o 

o 


CO 


— 

1  *  I  :l 


o 


Ph 


3  5-2 

•J  .H  n 


5"H 
So 

<T5    **3 


u  s 

S   o 


^  a 


north  and  south,  and  the  operating  room  and  laboratory  are  locat- 
ed in  the  north  side  of  the  building  in  order  to  secure  satisfactory 
light.  The  elevator  is  placed  in  the  square  space,  which  is  entirely 
separate  from  the  main  halls,  first  by  means  of  swinging  doors, 
separating  the  general  corridor  into  three  portions,  the  central 
portion  being  the  space  occupied  by  the  elevators  and  stairs.    This 


GENERAL    CONSIDERATION    OF    HOSPITAL    PLANS 


-IS!) 


arrangement  prevents  the  relatives  and  friends  of  patients  sick 
with  contagious  diseases  from  coming  in  contact  with  these  pa- 
tients when  they  call  for  information,  or  for  any  other  purpose 
that  would  necessitate  their  entering  the  department  of  admin- 
istration. This  also  places  all  of  the  patients  above  the  first  floor, 
and  consequently  away  from  the  dampness  of  the  earth,  and  high 


fig.  309. 
general  hospital  at  fran  k  fort,  germany,  l891.     75  beds. 

A.  Wash  stand.     B.   Sink.     C.   Sterilizer.     I ).   [nstrumenl   case,     E     Bottle   stand. 
F.  Operating  table.     ( \.   Wardrobe. 

enough  up  to  insure  relatively  good  air.  All  the  floors  above  the 
first  may  be  constructed  in  a  general  way  after  the  plan  indicated 
in  Figure  315.  In  a  city  sufficiently  large  to  require  an  entire 
floor  or  pavilion  for  each  disease,  there  should  of  course  be  built 


4!  to 


GENERAL    CONSIDERATION    OF    HOSPITAL  PLAXS 


I       — ■  i .  i t  •  i » i ' — i 

FIG.   310. 
RUDOLPH    VIRCHOW    (  I'I'V    HOSPITAL,    BERLIN,    1890.        L,627    BEDS. 

i.  Receiving  building.  2.  Administration  building.  3.  Nurses'  building.  4.  18. 
Patients'  buildings.  19.  Bathhouse.  20.  Operating  building.  21.  Gymnasium.  22. 
Chapel.  23.  Mortuary.  24.  Stable  for  animals  foi  experiment.  25.  Crematory  for 
animals  for  experiment.  26.  Disinfection  building.  27.  Pharmacy.  28.  Porter's  house. 
29.  Officers'  residence.  30.  Kitchen  building.  31.  Laundry  building.  32.  Boiler  build- 
ing- 33-  Water  tower.  34.  Grading  works.  35-  Coal  shed.  36  Repair  shops.  37. 
Wagon    sheds. 


GENERAL   CONSIDERATION    OF    HOSPITAL   PLANS 


491 


CO 


492 


GENERAL    CONSIDERATION    OF    HOSPITAL,   PLANS 


GENERAL    CONSIDERATION    OE    HOSPITAL    PLANS 


493 


above  the  first  floor  as  many  pavilions  or  floors  as  there  are  preva- 
lent contagious  diseases.  The  diseases  ordinarily  provided  for 
in  these  hospitals  are  diphtheria,  scarlet  fever,  measles,  whooping 
cough,  erysipelas,  and  in  some  communities  a  pavilion  is  required 
for  smallpox.  This  plan-  might  also  include  several  floors  that 
could  be  placed  at  the  disposal  of  patients  in  case  of  a  large  epi- 
demic of  any  one  of  the  contagious  diseases. 

On  each  floor  of  such  a  hospital  there  should  be  a  single  room 
in  which  patients  could  be  placed  for  observation  when  there  is 


5a5E/\l/it  Pla/i.  —  -«— ^M 

Hospital  For  Treatval/it. 
Or  Co/itagious   Diseases 

Meyer  J.    Sturm.   Architect. 

pig.  313. 

doubt  concerning  the  specific  character  of  their  disease,  and  the 

wards  to  which  they  should  be  assigned. 

In  plan  315  each  ward  could  ii  necessary  easily  be  changed 
into  two  smaller  ones  by  the  addition  of  a  partition  and  the  cutting 
of  a  second  door  into  two  private  rooms.  In  fact,  in  the  construc- 
tion of  such  hospitals  [i  would  be  wise  !<»  have  several  floors  eon 
taining  wards  as  shown  in  315,  which  could  be  divided  up  into 
small  wards,  or  into  private  rooms  to  be  occupied  by  private  pa- 


494 


GENERAL    CONSIDERATION    OF    HOSPITAL   PLANS 


tients  suffering  from  contagious  diseases.  A  further  advantage 
in  building  a  contagious  hospital  after  this  plan  is  to  be  able  to  not 
only  enlarge  it  by  adding  more  stories  to  increase  the  height,  but 
it  may  he  increased  in  length  by  adding  to  either  or  both  ends. 
In  most  cities  the  original  building  is  likely  to  he  built  too  small, 
and  with  the  increase  in  patronage  an  increase  in  the  size  of  the 
building  becomes  necessary. 

In  a  building  which  will  ultimately  require  an  entire  floor  for 
the  treatment  of  one  contagious  disease,  it  will  be  well  to  build 
at   least  live  stories,  hut  to  finish  only  the  first  story  for  adminis- 


riR">T  Floor  Pla/i  . 

Hospital  Tor  Trlatal/it. 

Or  C.O/1TAGIOU5     Dlir.A'jEj. 

Meyer  J.    Sturm,  Architect. 
FIG.  314. 

tralioti  and  the  second  and  third  stories  according  to  the  plan 
indicated  in  315,  where  one  pavilion  or  floor  is  made  into  two 
wards  to  accommodate  two  different  diseases. 

It  will  be  seen  that  the  dumb  waiter  opens  into  each  one  of  the 
service  room-  on  successive  floors,  and  it  might  he  supposed  that 
this  would  entail  the  danger  of  accidental  infection,  hut,  as  has 
been  pointed  out  before,  all  of  the  dishes  and  all  of  the  linen  that 
goes  back  to  the  floors  is  first  sterilized.  Another  objection  might 
he  raised  because  of  the  fact  that  all  patients,  without  regard  to 


GENEBAL   CONSIDER  \ ]  l<  >X    OF    HOSPITAL   PLANS 


4!)o 


their  disease,  are  carried  to  their  respective  floors  in  the  same  ele- 
vator. It  is  an  easy  matter  to  prevent  infection  from  this  source. 
The  patient  is  brought  to  the  hospital  on  a  stretcher,  preferably  m 
the  form  of  a  long,  narrow  basket.  The  patient  is  placed  in  this 
basket  between  two  sterile  sheets  made  of  drilling  seven  feet  long 
and  six  feet  wide.  These  sheets  are  folded  to  cover  the  patient 
completely  and  when  the  ambulance  arrives  at  the  hospital  the 
basket  is  placed  upon  the  wheel  stretcher,  which  is  also  covered 
with  two  sterile  sheets,  which  are  folded  over  both  basket  and 
patient,  and  not  opened  until  the  wheel  stretcher  stops  at  side  of 
the  patient's  bed.    After  removing  the  patient  from  the  stretcher 


«- 


^-JlJL^z 


b  LCO/1 D  t  LOOP  PLA/1 

Hospital  For  Treats  l/it 
Or  Co/iTAGiom  Di:>la3l:> 

Meyer  J.    Sturm,   Architect. 
FIG.  315. 

the  latter  is  enveloped  in  fresh  sterile  sheets,  and  the  sheets  that 
have  been  used  around  the  patient  are  sterilized  on  the  floor  he- 
fore  sending  them  to  the  laundry. 

In  a  contagious  hospital  more  than  in  any  other  it  is  impor- 
tant that  the  nurses  have  a  separate  building  for  a  nurses'  home, 
that  they  may  get  entirely  away  from  their  patients  after  their 
day's  work  is  finished. 


496  GENERAL   CONSIDERATION    OF    HOSPITAL   PLANS 

RECENT  HOSPITALS. 

Figure  316  represents  a  plan  which  has  been  employed  quite 
extensively  during  the  last  two  decades.  The  space  between  the 
elevator,  toilet,  bath  and  service  rooms  being  utilized  as  a  diet 
kitchen,  connected  with  the  general  kitchen  by  means  of  a  dumb 
waiter.  This  form  of  construction  was  selected  because  of  the  de- 
sire  to  have  a  south  exposure  for  every  room,  and  au  east  and 
west  exposure  for  the  hall.  In  this  case  one-third  of  the  floor 
-pare  is  occupied  by  the  hall,  one-half  of  the  remaining  space  by 
the  elevator,  hath  and  service  rooms,  leaving  only  one-half  of  the 
•  •at ire  space  for  the  use  of  patients.  It  can  be  readily  seen  that 
this  form  of  construction  must  be  at  least  50  per  cent,  more  ex- 
pensive than  the  form  of  construction  described  in  Fig.  287.  It  is 
equally  plain  that  the  running  expenses  of  such  a  hospital  will  be 
considerably  greater. 

By  removing  three  of  the  partitions  in  this  plan  the  six  single 
rooms  will  be  changed  into  three  wards,  each  capable  of  accommo- 
dating four  patients. 

A  single,  many-storied  pavilion  constructed  on  this  plan  can, 
of  course,  be  enlarged  to  any  desirable  size  by  adding  to  the  length, 
or  by  additional  stories.  The  disadvantages  in  this  plan  outweigh 
t.Ee  advantages,  and  it  is  described  here  only  with  the  view  of  pre- 
venting others  from  repeating  the  errors. 

Figures  .*!17,  318,  319  represent  a  hospital  planned  on  the  gen- 
eral principles  represented  in  Figures  286  to  289,  with  the  excep- 
tion that  this  institution  had  to  be  constructed  upon  a  triangular 
shaped  piece  of  land. 

Figure  317  represents  the  top  floor,  the  uorth  end  marked 
"0"  being  used  for  operating  rooms.  Each  one  of  these  operat- 
ing rooms  has  a  very  large  north  skylight,  supplying  an  abun- 
dance of  diffused  light.  On  this  floor  also  are  all  the  other  con- 
veniences for  the  operating  department,  such  as  anesthetizing 
room,  "M";  sterilizing  room,  "F";  room  for  storing  sterilized 
supplies,  "H";  general  storeroom  and  service  rooms,  "S";  in- 
s\  lMinient  room,  "I";  X-ray  room,  "  X  " ;  recovery  room,  "A,"  and 
surgeon's  dressing  and  locker  room  with  shower  and  bath,  "T." 
There  are  two  rooms,  "D,"  to  which  patients  are  taken  for  gen- 
eral dressings. 

The  recovery  wards  ar<^  of  the  greatest  benefit  to  patients 
recently  operated  upon,  as  they  are  in  charge  of  senior  nurses  and 
not  removed  to  the  general  ward  until  they  are  in  a  condition  not 
to  disturb  or  be  disturbed  by  the  other  patients.  In  this  plan  the 
recovery  ward  contains  three  beds,  which  seenis  sufficient  for  this 
hospital,  which  contains  one  hundred  and  fifty  ward  beds. 


GENERAL   CONSIDERATION    OF    HOSPITAL    PLANS  l-9< 

The  recovery  wards  are  used  only  for  patients  occupying 
ward  beds.  It  might  be  well  to  provide  a  few  single  rooms  on 
the  operating  room  floor  to  be  used  as  recovery  rooms  for  patients 


pig.  316. 

occupying  private   rooms.      The   entire   operating   department    is 
isolated  from  the  rest  of  the  hospital,  which  adds  much  to  the 


498  ,,I.NI,KAI.   CONSIDEUiTIOH    OF    HOSPITAL   FLANS 

,.,„„,■„„  0f  the  patients  and  relieves  the  hospital  of  mnch  confn- 


sion. 


This   Wan  also  gives  an  ideal  operating  department     It  is 
located  nearly  one  hnndred  feet  from  the  ground,  whore  the  an 


FIG.  317. 
,  o-     ,    ,-,  t    r   Rallbere  Meyer  \.  Sturm.  Architects. 

Augustana  Hospital.  Plan  of  Sixth  Floor.    L.  G.  Hallberg,  Mey 

i     p        fvn,,  ^treel   .lu-'      H    s  isolated  from  the 
'-  pnTrmaratively  tree  I  mm  sinci  uu  ..  _ 

UTthe  hospital  and  i ^^**  <£'£££ 

, lingly  small  expense,  the  enta   cost  ol   the  department 


GENERAL    CONSIDERATION    OF    HOSPITAL    FLANS 


499 


being  less  than  $15,000.  Had  the  same  conveniences  been  secured 
by  the  construction  of  a  separate  operating  pavilion,  the  cost 
would  have  been  three  or  four  times  this  amount.     This  depart- 


ftg.  318. 

L.  G.  Hallberg,  Meyer  .1    Sturm,  Architects 

rnent  is  sufficiently  large  for  a  hospital  of  300  surgical  beds.  Were 
all  of  them  ward  beds,  however,  it  would  be  necessary  to  have  two 
or  three  additional  three-bed  recovery  wards. 

The  west   half  of  the  south  end  of  this  floor  is  occupied  by 


500 


GENERAL    <  o\SI  DKRATIuX    OF    HOSPITAL    PLANS 


the  kitchen  "K,"  the  room  for  kitchen  stores  "Z,"  the  baking 
room  4'J,"  the  pantry  "IV  and  the  dining  room  "U."  At  c 
there  is  a  door  separating  the  kitchen  department  and  the  dining 


FIG.  319. 
L.  G.   Hallberg,  Meyer  J.  Sturm.  Architects. 

rooms  from  the  surgical  department.  The  dining  room  has  oeen 
divided  into  two  rooms,  one  for  servants  and  the  other  for  nurses 
and  residenl  physicians.  The  east  half  of  the  west  end  of  the 
)uilding  is  occupied  by  the  obstetrical  department. 


GENERAL    CONSIDERATION    OF    HOSPITAL    PLANS  503 

The  two  elevators  "E"  are  badly  placed.  They  should  have 
been  placed  as  indicated  in  Figs.  286,  287,  288,  289. 

The  room  marked  "V"  just  south  of  the  elevator  has  been 
changed  into  a  special  diet  kitchen,  and  notwithstanding  its  faulty 
position  has  been  of  great  benefit  and  convenience  to  the  institu- 
tion. 

At  this  point  it  may  be  well  to  again  direct  attention  to  the 
possibility  of  arranging  the  top  floor  in  this  plan  in  any  way  de- 
sired without  regard  to  the  arrangement  of  the  outside  walls, 
because  perfect  lighting  and  ventilation  can  be  secured  by  the 
proper  placing  of  skylights  and  flues.  (See  plans  for  model 
kitchen  and  operating  departments.)  "With  the  proper  placing 
of  ventilating  flues  the  odors  from  cooking  and  from  the  anes- 
thetics in  the  operating  rooms  can  be  absolutely  removed  from  the 
building.  This  arrangement  has  been  tried  and  found  to  be  per- 
fectly satisfactory. 

Figure  318  represents  the  fourth  and  fifth  floors  of  this  same 
building.  They  contain  twenty-two  private  rooms,  eight  of  them 
with  private  baths,  and  four  others  forming  a  suite  with  a  private 
bath.  The  floor  plan  also  contains  two  general  baths  and  toilet 
rooms  "T."  There  are  two  storerooms  "L"  and  ;'Z,"  and  a  diet 
kitchen  "K."  The  service  rooms  are  separated  by  a  six-foot  par- 
tition. A  dumb  waiter  in  the  northeast  corner  of  the  diet  kitchen 
runs  to  the  kitchen  on  the  top  floor,  but  this  is  not  shown  in  Figure 
318.  This  arrangement  fills  all  the  requirements  of  a  first-class 
hospital. 

It  is  very  important  in  this  class  of  hospitals  to  have  all  the 
floors  so  arranged  that  each  individual  floor  contains  only  private 
rooms  or  only  wards,  because  the  mixing  of  private  rooms  and 
wards  on  the  same  floors  has  invariably  given  rise  to  endless  an- 
noyance. 

Figure  319  represents  the  second  and  third  floors  of  the  same 
hospital.  These  floors  are  occupied  entirely  by  wards  containing 
3,  4,  5,  6,  7,  8  and  16  beds.  Experience  has  shown  that  wards  with 
four  beds  are  more  satisfactory  than  any  others.  It  is  possible 
with  wards  of  this  size  to  place  patients  together  so  that  lliey  arc 
congenial.  It  is  possible  to  place  those  who  arc  very  ill  or  very 
recently  operated  in  the  same  ward,  which  will  prevent  annoyance 
to  others  less  ill.  Moreover,  the  additional  attention  that  nrnsl 
be  given  to  these  patients  will  not  cause  others  less  ill  to  become 
jealous  because  they  do  not  receive  the  special  attention  given 
those  who  are  more  needful  therof.  A  nurse  can  care  for  one  of 
these  wards  if  the  patients  are  quite  ill.  If  they  are  extremely 
ill  she  may  be  given  a  junioi    nurse  as  an  assistant,      [f  the  pa- 


502  GENERAL    CONSIDERATION    OF    HOSPITAL   PLANS 

tients  arc  all  convalescent  she  may  care  for  two  of  these  wards, 
either  alone  or  with  the  aid  of  an  assistant.  In  every  instance 
each  nurse  will  take  an  especial  pride  in  her  ward  and  there  will 
he  developed  a  wholesome  rivalry  between  the  nurses  in  charge 
of  the  various  wards,  a  condition  which  cannot  be  obtained  bene- 
ficially if  patients  are  placed  in  Large  wards.  The  large  wards  at 
south  end  of  this  building,  which  were  part  of  the  old  building 
constructed  some  years  ago,  would  be  much  more  valuable  had 
they  been  divided  into  smaller  wards.  It  seems  that  there  can  be 
no  good  reason  for  constructing  a  ward  for  more  than  eight  beds. 

Small  wards  are  especially  valuable  in  hospitals  connected 
with  medical  schools,  because  one  or  more  of  these  wards  can  be 
regularly  assigned  to  a  senior  ami  a  junior  student  for  a  definite 
period  of  time.  In  this  manner  the  student  has  an  opportunity  to 
observe  a  definite  number  of  patients  from  the  time  they  enter 
the  ward  until  they  are  discharged.  In  this  way  conditions  are 
established  between  the  student  and  the  patient  similar  to  those 
that  exist  between  the  physician  and  his  patient  in  private  prac- 
tice, which  makes  the  bedside  work  of  the  student  really  valuable, 
at  the  same  time  the  patient's  comfort  is  not  disturbed  and  as  he 
is  under  the  direct  care  of  a  member  of  the  faculty,  the  patient, 
the  student  and  the  hospital  are  simultaneously  benefited. 

Even  in  state,  county  or  city  hospitals  it  seems  wise  that  in 
the  future  wards  should  be  built  for  not  more  than  eight  beds. 
All  of  these  hospitals  should  be  utilized  for  teaching  purposes  ami 
the  small  ward  will  aid  materially  in  making  profitable  scientific 
bedside  teaching  in  these  institutions. 

One  of  the  floors  in  319  is  occupied  entirely  by  male  patients 
and  the  other  by  females.  With  elevators  placed  as  shown  in  this 
volume,  these  two  floors  would  be  completely  isolated  from  each 
other  and  from  the  private  floors,  and  also  from  the  first  floor, 
which  in  this  instance  is  occupied  by  the  general  offices,  the  office 
of  the  general  superintendent,  that  of  the  superintendent  of  nurses, 
the  waiting  room,  the  examining  rooms,  the  library,  the  labora- 
tory, the  chapel  and  the  rooms  of  the  resident  'physicians  and  sur- 
geons. 

In  this  manner  one  can  obtain  the  advantages  of  concentra- 
tion which  results  in  economy  combined  with  excellence  of  serv- 
ice. At  the  same  time  il  is  possible  to  isolate  the  floors  so  thor- 
oughly that  each  floor  affords  the  comforts  to  the  patient  that  he 
could  obtain   were  he  to  be  in  an  entirely  separated  building. 

This  subject  has  been  treated  so  fully  in  order  to  impress 
those  interested  that  this  plan  has  been  thoroughly  tried  out  and 
found   most   satisfactory  and   because  this  plan  applies   to  condi- 


GENERAL    CONSIDERATION    OF    HOSPITAL   PLANS 


503 


tions  such  as  exist  in  most  communities  in  this  country  in  which 
the  construction  of  hospitals  is  contemplated. 

Figure  320  represents  a  form  of  construction  which  must  in 
time  become  popular.  If  placed  so  that  the  open  side  of  the  k '  U ' 
faces  south,  with  the  elevators,  stairways,  hath  and  toilet  rooms, 
kitchen  and  operating  rooms  situated  along  the  north  wall,  every 
hall,  room  and  ward  in  the  building  occupied  by  patients  will  be 
exposed  to  the  sunlight  for  a  considerable  portion  of  the  day. 

i 


Meyer  J.  Sturm    Architect 


FIG.   320. 


The  main  entrance  can  be  placed  in  the  courl  side  of  the  cross 
building  if  south  faces  the  principal  street.  Such  a  building  can 
be  easily  ventilated  and  heated.  The  relative  cost  of  construction 
is  small  for  the  amount  of  utility  obtained.  The  size  can,  if  de- 
sired, he  increased  by  lengthening  the  parallel  wings  and  by 
increasing  the  number  of  stories,  it  is,  however,  important  that 
the  height  of  the  parallel  wings  docs  not  exceed  the  distance  be- 
tween the  wings,  ami  that  the  length  he  less  than  twice  the  dis- 
tance between  the  wings.     Unless  these  precautions  are  heeded 


504  GENERAL    CONSIDERATION    OF    HOSPITAL   PLANS 

shadows  will  be  thrown  which  will  interfere  with  the  proper  sun- 
ning of  the  windows  directed  toward  the  court,  An  explanation  of 
this  can  be  found  in  the  section  of  Orientation  of  Hospitals. 

In  about  the  middle  of  each  parallel  wing  should  be  placed 
toilet,  bath  and  service  rooms,  in  order  to  shorten  the  distances 
for  nurses  to  walk  while  caring  for  their  patients.  Along  the 
north  wall  may  be  placed  treatment  rooms  for  the  various  special- 
ists, examining  rooms,  X-ray  room,  and  the  dark  rooms  to  be  oc- 
cupied by  eye  patients. 

One  of  the  wings  may  be  assigned  to  men  and  the  other  to 
women,  or  one  or  more  floors  may  be  assigned  to  each  sex.  It 
may  also  be  arranged  to  have  each  floor  or  each  wing  assigned 
to  one  member  of  the  medical  staff  and  placed  under  his  entire 
control  as  though  it  were  a  separate  hospital. 

The  hospital  may  be  arranged  in  wards  of  any  desired  size, 
or  in  private  rooms,  and  the  private  rooms  may  be  provided  with 
baths  according  to  the  conditions  best  suited  for  the  institution  in 
question.  The  possibilities  for  excellence  and  economy  of  con- 
duct in  this  form  of  hospital  construction  is  excelled  only  by  the 
plan  described  in  Figures  286  to  289. 

Figures  321,  322,  323  represent  a  hospital  constructed  on  the 
general  plan  of  the  one  just  described,  except  that  the  building  is 
placed  with  the  parallel  wings  extending  from  east  to  west,  in- 
stead of  from  north  to  south.  In  this  instance  conditions  of  sec- 
ondary importance  determined  the  placing  of  the  building  in  this 
position.  It  is  doubtful  if  it  is  ever  wise  to  so  locate  this  form  of 
a  hospital,  as  the  results  are  so  much  more  satisfactory  when  the 
structure  is  placed  in  the  opposite  direction.  In  order  to  over- 
come the  defects  the  following  plan  is  offered:  The  parallel  wings 
are  made  relatively  short,  thus  exposing  a  very  long  eastern  wall 
to  the  morning  sun.  The  elevators,  stairs  and  bathrooms  are  sit- 
uated in  the  corners  of  the  courts.  In  this  manner  there  is  but  one 
room  without  sun  in  the  south  wing  and  four  rooms  without  sun 
in  the  north  wing.  By  transferring  the  elevators  and  stairs  to 
the  corners  on  each  side,  just  east  of  the  bath  rooms,  and  the 
bath  and  toilet  in  the  north  wing  to  the  space  occupied  by  the  two 
eastern  rooms  on  the  north  side  of  the  hall,  four  more  sunny 
rooms  could  be  secured.  By  placing  a  west  window  in  each  room 
at  the  west  end  of  the  two  wings,  there  would  be  left  but  one 
room  on  the  entire  floor  (Fig.  321 )  without  sunlight. 

In  this  plan  the  location  of  the  diet  kitchen  "K"  was  deter- 
mined by  the  location  of  the  general  kitchen,  on  the  first  floor  of  a 
separate  building  between  the  two  parallel  wings.  The  kitchen 
would  be  much  more  satisfactory  if  located  on  the  top  floor,  where 


GENERAL  CONSIDERATION   OF  HOSPITAL  PLANS 


505 


the  odor  from  the  cooking  would  not  penetrate  to  the  rest  of  the 
building.  While  it  is  beautifully  and  conveniently  planned,  and 
while  it  would  entail  a  considerable  cost  to  transfer  it  to  the  top 
floor,  yet  this  will  undoubtedly  be  done  sooner  or  later. 


CO 

to 


K     £ 


g.    W    3 


7T       5: 


> 


n 


The  windows  were  placed  in  the  west  walls  of  fche  wings 
as  the  original  plans  provided  for  enlarging  the  building  by 
lengthening  the  parallel  wings  to  the  west.  This  should  be  done 
by  placing  an  outside  c*our1  in  the  north  wall  on  each  wing,  as 
shown  in  Figure  324.     In  this  manner  the  hall  will  receive  addi- 


506 


GENERAL   COX  SI  DERATION    OF    HOSPITAL,   PLANS 


tional  light,  and  four  rooms  which  would  otherwise  be  entirely 
without  sun  will  receive  east  or  west  sunlight.  By  making  this 
court  sufficiently  wide  only  one  room  is  lost  in  each  wing,  and  that 
is  well  paid  for  by  the  additional  sunlight  it  will  provide  for  the 
rooms  in  question. 


cu 


^  is 


E    < 


.■a    on 


CO 

c 

M 


Figure  322  shows  the  wai'd  floors  in  the  same  hospital.  These 
wards  contain  from  tour  to  eight  beds  and  every  ward  has  sun- 
light. There  is  also  an  isolation  room  "V"  in  each  wing,  each  one 
of  which  should  have  a  wesi  window,  the  one  in  the  north  wing 


GENERAL    CONSIDERATION    OF    HOSl'ITAL   PLANS 


507 


would  later  be  closed  when  the  building  is  enlarged,  but  this 
would  not  be  important,  as  the  room  would  still  have  a  south 
window. 

The  lockers  in  which  patients'  clothing  is  kept  after  it  has 
been  cleaned  and  sterilized  has  been  found  a  great  convenience  in 
this  institution. 

By  placing  a  court  in  the  north  wall  of  each  wing  for  every 
sixty  feet  added  to  the  length  of  the  wings,  there  will  be  but  two 


— «- 


St.    Mary's   Hospital.      Part   of  Fifth   Floor. 
Henry  J.  Schlacks,  Architect. 

fig.  323. 

rooms  in  each  wing  without  sunlight  and  each  ward  on  the  north 
side  of  the  halls  will  have  both  east  and  west  sunlight  if  the  en- 
tire space  is  left  as  a  single  ward.  If  it  is  divided  into  two  smaller 
wards  each  one  of  these  will  have  either  east  or  west  sun.  AM  the 
rooms  on  the  south  side  of  this  hall  will,  of  course,  have  sunlight 
all  day  long.  In  case  more  than  a  hundred  feet  in  length  is  added 
to  each  of  these  wings,  it  will  be  necessary  to  place  another  service 
room  on  the  north  side  of  each  hall  in  order  to  reduce  the  work 
of  the  nurses.  By  following  these  suggestions  the  results  obtained 
will  be  fairly  satisfactory  in  case  the  enlargement  of  the  hospital 
should  be  desired. 

Figures  325,  326,  :V27,  328.  329,  330  represent  a  plan  which 
must  ultimately  become  popular  for  large  municipal,  state,  count} 
or  city  hospitals  where  it  is  especially  desirable  to  have  separate 
departments  for  male  and  female  patients.  As  shown  in  Figure 
331,  this  plan  is  provided  with  a  central  administration  building 
with  two  parallel  wings  Oil  either  side  for  patients.     These  wing- 


508 


GENERAL   CONSIDERATION    OF   HOSPITAL    PLANS 


extend  from  north  to  south.  There  is  also  provided  in  a  separate 
building  an  out-patient  department  with  an  operating  department 
in  the  second  story  which  will  serve  for  both  wings. 

It  is  well  to  locate  the  heating  and  power  plant,  the  elevators 


fig.  324. 
and  dumb  waiters,  the  morgue,  laundry,  ironing  room  and  mend- 
ing room  in  the  first  story  of  this  building.    The  entrances  to  each 
of  these  departments  can  be  so  arranged  that  they  will  in  no  way 
interfere  with  each  other. 


GENERAL,   CONSIDERATION    OF    HOSPITAL   PLANS 


509 


The  entrance  to  the  out-patient  department  should  be  on  the 
north  side  of  the  building,  so  that  the  patients  coming  to  this 
department  will  not  come  in  contact  with  the  hospital  patients 
proper.  It  is  desirable  that  these  two  buildings  have  different 
street  entrances,  which  will  save  the  officials  of  both  departments 
much  confusion  and  trouble. 


— «— 


V/apd  Floor  Pla.i  Pooa\  noon  Pla.i 

BUILDI/1G-   B 

A    City     M o 5 p i t a l 

FIG.  325.  fig.  326. 

Meyer  j.  Sturm.  Architect. 

In  case  the  hospital  does  not  contain  an  out-patient  depart- 
ment it  is  well  to  place  the  wards  for  patients  suffering  from  con 
tagious  diseases  in  the  second  story,  according  to  the  plan  already 
described.  These  wards  would,  of  course,  be  reserved  for  patients 
developing  contagious  diseases  in  the  hospital.  In  case  patients 
suffering  from  contagious  diseases  are  received  for  treatment  in 
the  institution,  a  separate  pavilion  should  be  built  for  tho  purpose. 


510 


GENERAL   CONSIDERATION    OF    HOSPITAL    PLANS 


It  would  be  quite  proper  to  have  the  boiler  room,  laundry, 
etc.,  iu  the  first  story,  the  out-patient  department  in  the  second 
story,  the  department  for  the  treatment  of  contagious  diseases 
developing  in  the  hospital  in  the  third  story,  and  the  operating 
and  recovery  rooms  in  the  fourth  story.  This  would  necessitate 
building  the  administration   building  three  stories  high  and   the 


FlBiT  Floop  Pla/i- 
Bi  ii  rii  ig-  A 

A    City    Hospital 


fig.  327. 

.Meyer  J.   Sturm,  Architect. 

roof  of  this  building  should  be  connected  by  a  bridge  to  the  parallel 
wings,  and  also  to  the  story  containing  the  operating  department. 
It  is  important  in  this  plan  to  have  high  basements  under  the 
parallel  wings,  as  patients  will  be  housed  on  the  first  floors  and 
they  will  in  this  way  be  farther  removed  from  the  unhygienic  con- 
ditions which  come  from  close  proximity  to  the  ground. 

Another  arrangement  which  is  entirely  proper  in  connection 
with  this  general  plan  is  to  place  operating  and  recovery  rooms 
at  the  north  end  of  each  of  the  parallel  pavilions  (Figs.  325,  326), 
thus  providing  a  separate  operating  department  for  the  male  and 
female  divisions  of  the  house.  This  plan  provides  still  another 
advantage  which  is  important  in  the  organization  of  municipal 
hospitals  in  growing  communities.  One  parallel  wing  may  first 
be  constructed  and  the  floors  divided  between  the  male  and  female 


GENERAL    CONSIDERATION    OF    HOSPITAL    PLANS 


513 


patients.  Later  when  conditions  demand  accommodation  for  a 
larger  number  of  patients,  tlie  second  pavilion  may  be  constructed 
and  the  sexes  separated  in  the  two  pavilion.-. 

Figure  325  represents  the  entire  floor  divided  into  wards 
which  may  be  arranged  in  sizes  to  suit  the  conditions.  According 
to  this  plan  each  ward  has  either  morning  or  afternoon  sun  and 
the  hall  is  exposed  to  sunlight  at  midday.  The  elevators  and 
stairs  are  so  placed  that  each  floor  is  entirely  separated  from  every 
other  floor,  establishing  conditions  corresponding  to  those     de 


.1 


5lco/id  FloobPla/i 

Blildi/ig  -  A- 
A    City    Hospital 

fig.  328. 

Meyer  J.   Sturm,  Architect. 

scribed  in  connection  with  Figures  286  to  289.  The  rooms  for  the 
various  utilities  are  all  centrally  located,  leaving  a  very  high  per- 
centage of  space  for  housing  patients.  Should  one  or  more  private 
rooms  be  required,  either  with  or  without  private  bath,  this  can 
be  readily  accomplished  as  shown  in  Figure  326. 

The  details  of  the  administration  building  must  necessarily 
vary  with  the  particular  requirements,  and  therefore  no  exacl 
form  can  be  given.  Figs.  327,  328  show  an  arrangemenl  for  such 
a  building. 

Figure  329  represents  the  ont-patienl  department  for  a  large 
municipal  hospital,  the  main  feature  being  a  large  central  wail 


512 


GENERAL   CONSIDERATION    OF    HOSPITAL    PLANS 


ing  room  supplied  with  comfortable,  stationary  benches.  The 
entrance  to  this  waiting  room  is  in  no  way  connected  with  the 
hospital,  but  at  the  opposite  end  of  this  room  are  swinging  doors 
which  lead  into  a  hall  connecting  this  building  with  the  adminis- 
tration department  of  the  general  hospital.  These  doors  could  be 
kept  locked  if  complete  isolation  of  the  department  was  neces- 


BtllLDI/IG     C. 

A    City    Hospital 


riDIT  TLOOR  PLA.1 


Meyer  J.   Sturm,  Architect. 

fig.  329. 

sary.  This  plan  provides  a  large  number  of  examining  rooms. 
At  the  northern  extremity  of  the  building  there  should  be  rooms 
o(  I  nipped  for  operating  and  dressing  rooms  to  be  used  for  the 
treatment  of  minor  surgical  cases.  The  different  specialties  will, 
of  course,  require  particular  conveniences  in  the  various  examin- 
ing rooms,  but  these  are  details  which  must  be  provided  for  in 
individual   plans.     There  should  be  a  sterilizing  room,  a  patho- 


GENERAL    CONSIDERATION    OF    HOSPITAL   PLANS 


513 


logical  laboratory,  and  in  most  institutions  a  drug  room.  Each 
room  should  have  hot  and  cold  water. 

The  sketches  presented  here  are  intended  to  servo  only  by 
way  of  general  outline;  the  plans  for  each  department  would  nec- 
essarily vary  with  varying  conditions. 

Figure  330  represents  the  operating  rooms,  anesthetizing, 
dressing,  supply  and  recovery  rooms,  also  a  service  room  for  the 
nurses  in  charge  of  this  department. 


BlIILDI/lG     C. 

A    City  Hospital 


—9o;— 


^tCO/tD  Ploop  Pla/i 


Meyer  J.   Sturm.  Architect. 

pig.  330. 

Provision  is  also  made  for  an  amphitheatre  for  the  use  of 
students  in  connection  witli  the  large  centra]  operating  room  that 
extends  over  the  anesthetizing  rooms  and  further  over  th<>  two 
small  operating  rooms  on  either  side  of  the  la  rue  central  <>i  'orat- 
ing room. 

The  anesthetizing  rooms  are  located  so  thai  they  can  ho  util- 
ized for  either  the  small  or  the  large  operating  rooms.     Tt  would 


514 


GENERAL    CONSIDERATION    OF    HOSPITAL   PLANS 


be  well  to  use  them  also  for  dressing  rooms.  In  that  case  the 
room  marked  as  dressing  room  could  serve  as  a  further  recovery 
ward,  which  would  materially  increase  the  working  capacity  of 
i  he  department. 

The  small  dressing  room  should  be  changed  into  a  surgeons' 
dressing  room  with  shower  bath  and  toilet,  and  a  number  of  pri- 
vate lookers. 

This  operating  department  is  sufficient  for  a  hospital  contain- 
ing up  to  four  hundred  surgical  beds.    The  small  recovery  rooms 


1. 


B 


m 


B 


FIG.   331. 

A.  Figs.  327—328.     B.  Figs.  325-326.     C.   Figs.  328-329.     D.  Necropsy  and  Patho- 
logical  Building,  Morgue,  etc.     F.  Nurses'  Home. 
Meyer  J.   Sturm,  Architect. 


will  accommodate  from  two  to.  three,  the  larger  ones  from  four 
to  six  beds. 

This  arrangement  isolates  the  operating  department  from  the 
genera]  hospital  and  thus  does  away  with  the  annoyance  of  dis- 
agreeable odors  due  to  the  use  of  anesthetics  and  the  noise  of 
this  department.  Its  conduct  is  somewhat  more  expensive  than 
when  located  at  the  north  end  of  the  top  floor  of  the  pavilion  con- 
taining the  patients,  but  when  constructed  as  the  top  story  of  a 
separate  building,  as  in  the  plan  at  present  under  consideration, 
the  expense  of  construction  is  but  slightly  greater  than  it  would 
be  were  it  placed  as  described  in  the  previous  plans. 


GENERAL   CONSIDERATION    OF    HOSPITAL    PLANS  .~)15 

HOSPITALS  FOB  CHILDREN. 

Children  are  especially  liable  to  contagious  diseases,  partly 
because  they  have  not  the  wisdom  to  avoid  those  suffering  from 
the  infections  and  partly  owing  to  the  fact  that  adults  who  have 
them  in  charge  are  careless  in  their  safeguarding.  The  fact  that 
they  do  easily  acquire  contagions  diseases  from  contact  with  other 
children  furnishes  an  important  element  to  be  considered  in  the 
construction  of  hospitals  for  children. 

A  study  of  the  history  of  epidemics  in  children's  hospitals  in 
this  country  and  abroad  shows  definitely  the  danger  of  patients 
acquiring  the  contagions  diseases  while  in  hospitals  under  treat- 
ment for  the  relief  of  some  other  affection.  The  infections  most 
commonly  acquired  are  as  follows:  Gonorrheal  vaginitis,  scar- 
let fever,  diphtheria,  whooping  cough,  chicken  pox  and  pemphigus. 
To  these  might  be  added  pneumonia,  spinal  meningitis  and  tuber- 
culosis. 

It  has  been  found  that  three  provisions  of  management  are 
necessary  for  the  prevention  of  infections,  and  three  which  have 
reference  to  construction. 

The  first  provision  refers  to  the  examination  which  is  made 
preceding  the  admission  of  the  patient.  If  the  responsibility  of 
admitting  patients  is  placed  upon  a  single  member  of  the  staff. 
it  but  rarely  happens  that  a  patient  suffering  from  a  contagious 
disease  is  admitted  into  the  hospital.  In  case  of  doubt  the  patient 
should  be  isolated  until  a  positive  diagnosis  can  be  made. 

The  second  source  of  danger  comes  from  using  different  arti- 
cles promiscuously  among  the  children,  and  from  the  nurse  going 
from  one  child  to  another  without  washing  her  hands. 

The  third  danger  comes  from  indiscriminately  admitting  vis- 
itors into  the  wards. 

The  errors  in  construction  refer  first  to  a  lack  of  provision 
for  isolation.  In  every  suspicions  case  the  utmost  precaution 
should  be  taken  to  prevent  the  infection  of  other  children.  This 
can  be  accomplished  only  by  absolute  isolation,  provision  for 
which  will  be  discussed  in  "typical"  plan  for  children's  hospital. 

Figure  332  represents  one  floor  of  a  children's  hospital,  the 
two  halves  being  exact  duplicates  of  each  other,  one  intended  for 
the  care  of  boys,  the  other  for  girls.  It  has  been  found  besl  '<> 
separate  the  sexes  in  caring  for  children  more  than  ten  years  of 
age  (some  authorities  insist  upon  the  separation  above  the  age 
of  six). 

One  feature  carried  through  the  entire  plan  is  swinging  doors 
between  each  ward  and  the  adjoining  hall,  with  an  additional  pair 


516  GENERAL   CONSIDERATION    OF    HOSPITAL   PLANS 

of  swinging  doors  on  either  side  of  the  hall  immediately  in  front 
of  the  elevator.  Children  well  enough  to  be  up  and  about  are 
much  more  likely  to  remain  in  their  own  departments  if  these  are 
separated  from  the  remaining  portion  of  the  hospital  by  doors 
that  are  kept  constantly  closed. 

The  building  extends  from  north  to  south  so  that  every  room 
and  every  ward  is  exposed  to  the  morning  or  afternoon  sun  dur- 
ing some  portion  of  the  day.  The  hospital  can,  of  course,  be  en- 
larged to  suit  any  demand  for  capacity  by  lengthening  the  build- 
ing and  by  the  addition  of  further  stories. 

Each  wing  contains  three  large  wards,  each  with  a  capacity 
of  eight  beds,  and  two  private  rooms  which  could  contain  two  beds, 
although  they  are  intended  for  but  one.  There  are  also  two  isola- 
tion rooms  with  the  same  capacity.  There  are  toilet,  bath  and 
service  rooms  and  a  separate  dressing  room  and  toilet  for  the  use 
of  the  nurse.  A  diet  kitchen  is  connected  by  dumb  waiter  with 
the  general  kitchen  and  the  special  diet  kitchen,  which  are  located 
on  the  top  floor.  This  diet  kitchen  communicates  with  the  general 
hall,  and  it  communicatee  with  the  isolation  rooms  through  a 
glazed  door  leading  out  upon  a  bridge,  which  in  turn  leads  to  a 
glazed  door  opening  into  the  isolation  rooms.  Ordinarily  it  would 
not  be  necessary  to  use  this  bridge,  as  it  is  but  rarely  that  such 
absolute  isolation  is  required.  When  it  is  necessary,  however,  the 
double  doors  leading  into  the  general  hall  from  the  isolation  rooms 
are  closed  and  the  bridge  alone  used.  All  communication  is  car- 
ried on  by  telephone,  the  isolated  nurse  or  nurses,  if  one  is  em- 
ployed at  night  and  one  by  day,  occupy  one  of  the  rooms  and  the 
patient  the  other.  One  of  the  two  little  service  rooms  contains  a 
toilet,  and  a  steam  and  hot  water  combined  sterilizing  apparatus, 
the  other  contains  a  small  gas  or  an  electric  stove.  The  physician 
enters  the  rooms  after  he  has  completed  his  visits  to  the  other 
patients,  and  does  not  return  to  the  wards  after  leaving  this  de- 
partment.  His  clothing  is  protected  by  a  sterile  gown,  his  hands 
by  rubber  gloves,  which  are  sterilized  immediately  he  leaves  them 
in  the  isolation  rooms.  All  the  linen  used  in  this  department  is 
different  from  that  of  the  other  portion  of  the  hospital,  and  every- 
thing returned  to  the  hospital  proper  is  first  sterilized  and  then 
placed  in  a  sterile  bag. 

Ordinarily  one  of  these  isolation  departments  will  be  suffi- 
cient for  a  floor  containing  fifty  patients  and  the  other  isolation 
room  may  be  u^^l  for  children  who  are  especially  ill  or  noisy. 

In  case  it  seems  best  the  entire  floor  may  be  served  from  one 
diet  kitchen,,  the  door  leading  from  the  other  diet  kitchen  into  the 
hall  being  closed  and  the  room  utilized  in  connection  with  the  cor- 


GENERAL    CONSIDERATION    OF    HOSPITAL   PLANS  .11  < 

responding  isolation  rooms,  the  nurse  being  served  directly  from 
the  general  kitchen  and  from  the  special  diet  kitchen  through 
the  dumb  waiter.  In  this  case  all  the  dishes  should  be  sterilized  in 
the  general  diet  kitchen. 

An  important  feature  of  these  diet  kitchens  is  a  sterilizer  in 
which  all  dishes,  knives,  forks  and  spoons  arc  boiled  before  they 
are  returned  to  the  general  kitchen,  if  preferred,  they  may  be 
kept  in  a  cupboard  on  each  floor,  but  before  being  replaced  every- 
thing should  be  sterilized. 

Box  Wards.— The  box  ward  furnishes  a  means  whereby  a 
number  of  patients  may  be  placed  in  a  ward  without  danger  of 
mutual  infection,  in  case  one  of  the  patients  should  develop  a 
contagious  disease. 

The  simplest  and  least  objectionable  method  of  arranging  a 
box  ward  consists  in  placing  wire  glass  screens  four  feet  in  width 
and  six  feet  long,  mounted  on  nickel  frames,  which  stand  one  foot 
from  the  floor,  half  way  between  two  neighboring  beds. 

It  is  doubtful  whether  a  sitting  room  as  indicated  in  Figure  332 
is  an  advantage  in  a  children's  hospital.  The  plan  would  require 
an  additional  person  or  nurse  to  watch  the  children  in  such  sit- 
ting room,  as  they  should  not  be  left  alone.  It  has  been  suggested 
that  children  who  are  severely  ill  be  placed  in  one  ward;  those 
but  slightly  ill  in  another;  and  those  able  to  be  up  and  about  in 
a  third,  thus  making  a  comfortable  arrangement  and  saving  the 
services  of  an  additional  nurse. 

One  source  of  care  and  annoyance  of  officials  in  children's  hos- 
pitals comes  from  the  fact  that  mothers  are  so  often  determined 
to  remain  with  their  sick  children.  When  it  is  impossible  to  con- 
vince a  mother  that  the  child's  chances  for  recovery  are  better 
if  it  is  left  to  the  exclusive  care  of  the  nurse,  the  patient  should 
then  be  given  a  private  room.  The  mother  should  never  be  allowed 
to  remain  in  the  ward  and  thus  demoralize  the  discipline  of  the 
hospital,  and  of  the  other  children. 

In  every  children's  hospital  of  considerable  size  it  is  well  to 
have  a  separate  floor  provided  with  private  rooms  with  or  without 
private  baths.  These  floors  should  be  arranged  in  a  general  wav 
according  to  the  plans  described  in  Figure  288. 

In  Fig.  333  is  shown  a  form  of  hospital  built  in  1880,  in  which 
more  than  half  the  area  is  utilized  for  administration.  Tt  is  very 
expensive  in  construction,  two  stories  in  height,  the  second  story 
being  a  repetition  of  the  first  story.  It  provides  an  abundance 
of  sunlight,  good  ventilation,  and  a  greal  deal  of  space  lor  open 
air  treatment  on  the  verandas.  The  veranda  would  necessarily 
cut  off  considerable  sunlight  on  the  first  floor,  but   probably  not 


518 


GENEKAL    COXSlDKRAI'toX    o|'    I  !<  isi'li'A  \,    l'l.AXS 


EM         r 

r~      —       r 


GENERAL   CONSIDERATION    OF    HOSPITAL    PLANS 


7)1!) 


enough  to  be  objectionable  on  thai  account.     As  compared  with 
Fig.  332  for  the  same  amount  of  money  expended,  it  will  not  ac- 


ii, ;.  :\:v.\ 

commodate  as  many  patients,  nor  is  there  the  provision  made  for 
isolation,  which  is  so  necessarj  in  children's  hospitals. 


i.   Porter.     2.  Physician-in-Chief.    3.  Convalescent  building.    4.  Administration.    5 
Morgue.    6.  Steward.    7.  Female  employes.    8.  Male  employes.    9.  .Moat  and  fish  store- 

se.  10.  Kitchen  department.  11.  Internes'  department.  i_\  14.  Pavilions.  15.  Re- 
ceiving  ward.  10.  Laundry.  17.  Work  shop.  18.  Disinfecting  building.  19.  Nurses' 
home.     20.  Apprentices'  home.     21.  Night  nurses.     22.  Water  tower. 

Eight  pavilions  for  scarlet  fever,  forty-six  beds  each.  368:  four  pavilions  for  diph- 
theria, thirty  beds  each.  120:  six  isolation  pavilions,  ten  beds  each.  60;  total.  548. 


GENERAL   CONSIDERATION    OF    HOSPITAL   PLANS 


521- 


Fig.  334  is  an  example  of  a  pavilion  hospital,  which  covers  all 
available  space  to  such  an  extent  that  there  is  very  little  parkway 
left.  If  the  building  marked  12  and  13  had  been  made  into  a  ten- 
story  hospital,  and  the  service  buildings  had  been  placed  at  the 
rear  of  the  grounds,  this  hospital  would  have  been  provided  with 
large  park  space;  or  if  the  buildings  marked  7-8-9  and  10  had  been 
taken  as  the  administration  section  of  a  U-shaped  hospital  of  five 


fi*0O/A 


l_l 

PANTRY 

■ 

1 

,% 


t 


5I3TER.5  DIMiriG    POOM 


] 


itPVAMT.5     DiniMOr   POOM 


/ 


MUBitS   DirilMO    ROOM 


) 


PCCBCAIlOM    «OOA 


FIRCPPOOf      PORCH 


' 1     |W 

1 
Sinking-      1 

Jjo 

STORI 

Meyer  J.  Sturm,  Architect. 

fig.  335 

stories,  with  half  the  patients  in  one  wing  and  half  in  the  other, 
with  the  administration  between,  as  shown  on  the  U-shaped  plan 
in  this  book,  the  hospital  would  have  been  ideal.  An  arrangement 
such  as  shown  in  Fig.  331  would  also  have  been  superior  to  the 


522 


GENERAL   CONSIDERATION    OF    HOSPITAL   PLANS 


presenl  arrangement.  The  wings  and  floors  to  be  divided  as  shown 
in  Pigs.  313  to  315. 

Pig.  335  shows  an  operating  floor  on  the  L  shape.  This  hospi- 
tal was  laiilt  some  years  ago,  fonr  stories  in  height,  with  a 
high  sloping  roof  and  an  attic,  which  was  of  no  service  whatever, 
hi  remodeling  after  the  building  had  been  partly  destroyed  by  fire, 
the  above  plan  was  adopted  Tor  the  fifth  floor  and  a  flat  roof  put 
on.  In  the  room  connected  with  the  kitchen  marked  "stores"  has 
been  placed  a  diet  kitchen,  making  the  entire  kitchen  and  dining 


fig.  336 

room  department  isolated  and  practically  perfect,  the  operating 
and  isolation  departments  being  divided  from  the  remainder  of 
the  floor  as  shown.  The  kitchen  was  in  the  basement  before  re- 
modeling took  place. 


GENERAL    CONSIDERATION    OF    EfOSPITAL    PLANS 


523 


Fig.  336  shows  a  typical  four-bed  ward. 

Fig.  337  shows  the  general  arrangement  and  equipment  for  a 
private  room  in  a  hospital. 

Fig.  133  shows  the  general  arrangement  and  equipment  of  a 
private  room  in  a  hospital  connected  with  a  private  bath.  As  will 
be  seen  there  are  two  rooms  connected  with  each  such  bathroom, 
making  it  possible  to  use  these  rooms  en  suite,  or  one  room  with 
or  without  bathroom. 


Fig.  338  shows  an  operating  department,  each  operating  room 
having  an  anesthetizing  room  and  an  instrnmenl  room.  A  steril- 
izing room,  common  to  both,  is  placed  as  shown.  This  plan  IS  par 
ticularly  adaptable  to  building,  as  described  herein. 

Fig.  33!)  shows  a  plan  for  an  operating  departmenl  with  both 
the  anesthetizing  room  and  sterilizing  room  serving  both  operat- 
ing rooms. 


524 


GENEBAL   COXSIDERATIOX    OF    HOSPITAL   PLANS 


Meyer  J.   Sturm,  Architect. 

fig.  338. 


GENERAL    CONSIDERATION    OF    HOSPITAL    PLAN'S 


525 


Meyer  J.  Sturm,  Architect. 
FIG.  339. 


THE 
MANAGEMENT  OF  HOSPITALS 


CHAPTER  XXVII. 

GENERAL  SUPPLIES. 

CONTRACTS. 

It  may  seem  superfluous  to  speak  of  a  matter  so  thoroughly 
established  in  the  business  world  as  that  of  contracts,  materials 
and  supplies,  but  those  who  have  had  no  experience  in  the  con- 
struction and  management  of  hospitals — unless  they  are  familiar 
with  existing  conditions — may  find  to  their  sorrow  that  there  are 
certain  elements  which  must  he  considered  in  order  to  buy  the  best 
at  the  lowest  prices  for  the  quality  obtained.  This  has  developed 
from  the  fact  that  in  many  communities  materials  and  supplies 
for  hospitals  have  not  been  purchased  in  the  manner  they  would 
be  were  they  intended  for  any  other  enterprise,  for  instance,  the 
construction  of  a  hotel.  In  advertising  for  '"bids,"  it  frequently 
happens  that  the  Trustees  of  the  institution  feel  bound  to  consider 
only  those  bids  coming  from  the  church,  the  society  or  the  nation- 
ality represented  by  the  particular  hospital.  This  is  true  to  such 
an  extent  that  outside  bidders  do  not  as  a  rule  consider  it  worth 
while  to  compete.  One  authentic  instance  will  suffice  to  illustrate 
this  fact.  In  the  construction  of  a  foundation  for  a  hospital  the 
bids  of  those  who  were  presumably  eligible  because  they  belonged 
to  the  same  nationality  and  church,  varied  from  fourteen  thousand 
to  eighteen  thousand  dollars,  while  the  bid  of  the  contractor  be- 
longing neither  to  this  church  nor  religious  denomination  amounted 
to  eleven  thousand  five  hundred  dollars.  The  difference,  there- 
fore, between  this  and  the  lowest  of  the  other  bidders  amounted 
to  two  thousand  five  hundred  dollars,  which  would  have  given  a 
profit  of  five  hundred  dollars  to  each  of  the  five  competing  bid- 
ders. None  of  the  five  believed  that  the  hospital  organization 
would  dare  to  employ  a  contractor  who  was  not  of  their  national- 
ity and  a  member  of  their  church;  their  high  and  exorbitant  esti- 
mate was  a  result  of  the  feeling  of  security  against  outside  compe 
t  it  ion.  In  order  to  adjust  this  difficulty,  the  following  fatal  blun- 
der is  usually  made  by  Boards  of  Directors:  Bids  are  reopened, 
and  the  conditions  explained  to  these  various  contractors  who  are 
members  of  the  same  nationality  or  belong  to  the  same  societies 
or  religious  organizations.     All  competitors  arc  allowed  to  ma 


530  GENEBAL  SUPPLIES 

further  estimates,  when  it  will  probably  be  found  that  the  so-called 
inside  competitors  will  have  made  bids  equal  to,  or  lower,  than 
those  of  outside  contractors.  Directors  are  misled  into  taking 
this  step  because  there  are  two  distinct  advantages  to  be  gained 
from  the  method.  In  the  first  place,  i he  institution  obtains  its 
contract  at  as  low  a  rate  as  if  the  bids  had  been  honest  in  the  first 
instance;  in  the  second  place,  the  Trustees  are  not  blamed  for 
giving  contracts  to  those  outside  in  preference  to  their  own  peo- 
ple. 

There  is,  however,  an  objection  to  this  course,  as  it  indicates 
to  the  outside  contractors  that  it  is  useless  for  them  to  compete 
honestly,  and  consequently  the  field  is  left  free  to  the  dishonest 
competitors.  In  some  communities  this  fact  is  so  well  known  that 
contractors  do  not  consider  it  worth  while  to  spend  the  time  nec- 
essary for  estimating  the  cost  of  supplying  the  material  which  is 
called  for  by  the  contract,  and  consequently  only  tho?e  who  are 
-apposed  to  he  on  the  available  list  compete  for  these  privileges. 
It  is  an  easy  matter  for  these  contractors  to  form  combinations, 
to  the  detriment  of  the  corporation.  This  condition  is  the  result 
of  the  fact  that  these  institutions  ordinarily  try  to  get  more  for 
the  amount  of  money  expended  than  other  enterprises  would  ex- 
pect from  the  same  outlay,  for  after  having  made  a  contract,  the 
contractor  expects  to  be  called  upon  for  a  donation  for  the  insti- 
tution, and  he  tries  to  protect  himself  against  loss  by  over-charg- 
ing in  the  first  place,  and  then  appearing  to  be  generous  or  char- 
itable by  giving  it  back  to  the  institution  in  the  form  of  a  dona- 
tion. 

With  the  introduction  of  the  hospital  as  an  important  element 
in  the  community  these  objectionable  features  must  cease,  and  the 
plan  to  be  followed  by  any  given  institution  is  to  explain  to  con- 
tractor t|ia|  they  are  not  to  be  called  upon  for  donations,  and  if 
they  wish  to  obtain  the  contract  they  must  bid  precisely  as  they 
would  were  they  to  compete  for  contracts  for  any  other  enterprise. 
It  must  also  be  explained  to  them  that  the  contracts  will  be  given 
to  the  lowest  reliable  bidder,  without  regard  to  any  relation  he 
may  have  to  the  institution  in  a  social  and  religious  way,  or  from 
tin-  standpoint  of  his  nationality. 

THE  GRADING  OF  MATERIAL  AND  SUPPLIES. 

In  this  connection  the  matter  of  grading  materials  and  sup- 
plies musl  be  considered.  It  is  not  an  uncommon  experience  in 
the  construction  and  management  of  hospitals  to  find  that  one 
competitor  will  underbid  the  others  to  a  very  marked  extent  with 
the  expectation  of  forcing  upon  the  institution  a  quality  of  ma- 


<;i:.\  ERAL  SU  PPL  IKS  531 

terial  or  supplies  far  below  that  called  for  by  the  contract.  In 
case  the  contractor  belongs  to  the  same  nationality,  society 
or  religious  organization,  it  is  often  difficult  to  reject  material  and 
supplies  which  are  below  grade,  but  unless  this  is  insisted  upon 
the  institution  will  receive  a  very  poor  quality  of  material  and 
at  a  high  cost,  instead  of  receiving  a  high  grade  of  material  at  ;i 
low  cost.  This  is  not  an  uncommon  cause  of  waste  in  almost  every 
department  of  maintenance  of  the  institution. 

In  reviewing  the  lists  of  materials  purchased  one  finds  that 
in  almost  every  item  the  amount  of  material  of  a  good  quality  will 
go  farther  than  a  bad  quality  of  material.  This  is  not  only  true 
as  regards  the  primary  waste,  but  it  also  occurs  in  items  like 
furniture,  bedding,  ward  utensils,  instruments,  etc.  One  well- 
made  article  will  outlast  a  number  of  poorly  made.  The  natural 
care  given  to  well-made  things  is  much  greater  than  that  which 
is  given  to  things  of  an  inferior  quality,  which  fact  reduces  the 
amount  of  waste  in  the  first  respect. 

The  point  which  is  not  to  be  underestimated  in  this  connec- 
tion comes  from  the  establishment  of  a  reputation  for  the  institu- 
tion of  insisting  upon  the  quality  provided  by  the  contract.  Ex- 
perience has  shown  that -the  institution  which  invariably  rejects 
supplies  that  are  below  grade  is  certain  to  save  a  great  amount 
during  the  year,  because  those  who  furnish  the  supplies  find  it 
unprofitable  to  have  goods  rejected,  and  they  consequently  take 
the  pains  to  determine  that  their  materials  are  up  to  grade  before 
they  are  delivered. 

In  the  larger  institutions  practically  all  the  supplies  can  be 
contracted  for  at  stated  intervals.  In  these  instances  the  ordi- 
nary form  used  for  bids  by  business  men  in  other  industries  should 
be  employed  and  a  careful  record  kept  of  all  the  bids  received.  A 
record  should  also  be  kept  of  the  number  of  rejections  made  in 
connection  with  each  contractor,  for  in  this  manner  the  institu- 
tion can  soon  distinguish  reliable  contractors,  which  will,  <>f 
course,  be  of  great  value  in  making  future  contracts. 

In  the  smaller  institutions  which  do  not  require  supplies  in 
sufficient  quantities  to  make  it  profitable  for  important  business 
houses  to  make  contracts  with  them,  it  is  besl  to  use  the  following 
system:  Some  person  with  good  judgment  should  visit  the  vari 
ous  establishments  furnishing  supplies,  to  determine  the  quality 
of  goods  and  the  prices.  The  firm  giving  the  most  favorable  terms 
should  be  selected,  with  the  understanding  that  the  supplies  are 
to  remain  of  good  quality,  and  the  terms  reasonable,  and  thai  so 
long  as  these  requirements  are  maintained  all  of  the  supplies  ol 


032  GENERAL  SUPPLIES 

the  character  in  question  will   be  purchased  from  this  establish- 
ment. 

Observation  has  shown  this — that  several  hospitals  in  the 
same  city  may  purchase  a  given  supply  from  a  firm,  and  the  one 
thai  buys  from  the  same  establishment  year  after  year  will  find 
at  the  end  of  a  year  that  the  amount  paid  is  from  ten  to  twenty 
per  cent  less  than  that  paid  by  other  hospitals  not  following  this 
system.  This,  however,  is  the  ease  only  if  the  institution  pays  its 
hills  promptly.  The  reason  is  evident.  Without  the  additional 
expense,  which  would  he  necessary  wore  hills  not  paid  promptly, 
the  firm  supplying  the  given  material  can  make  a  small  hut  con- 
stant profit,  provided  the  slight  amount  of  attention  is  given  to 
the  necessary  inspection  of  supplies  to  determine  their  proper 
grade. 

PUECHASING    FOB  CASH. 

The  plan  of  purchasing  for  cash  is  of  sufficient  importance 
to  he  considered  separately.  In  buying  from  wholesale  houses 
from  two  to  six  per  cent  can  ho  saved  on  all  hills  by  paying-  cash. 
All  bills  providing  for  a  discount  for  cash  should  be  paid  at  once, 
if  necessary  before  they  are  audited,  but  they  should  be  carefully 
audited,  together  with  all  of  the  other  bills,  once  a  week,  in  the 
larger  institutions,  and.  once  a  month  in  the  smaller  institutions. 
The  fact  of  their  having  been  paid  before  they  were  audited  may 
occasionally  give  rise  to  some  slight  annoyance,  but  this  is  of  no 
Importance  compared  to  the  benefit  derived  by  the  institution  in 
saving  cash  discounts. 

It  requires  much  greater  ability  to  purchase  supplies  that  are 
of  high  grade  and  still  relatively  inexpensive,  than  one  inexperi- 
enced in  hospital  management  might  imagine,  but  the  amount 
saved  when  supplies  are  purchased  by  some  one  who  is  experi- 
enced in  this  line  is  enough  to  enable  even  a  small  hospital  to 
employ  a  person  with  proper  judgment  for  this  work. 

WASTE  OF  LABOR  AND  MATERIAL. 

Unless  one  has  given  the  subject  of  waste  in  the  management 
of  hospitals  close  attention  for  a  long  period  of  time,  it  is  impossi- 
ble to  comprehend  hew  much  material  is  ordinarily  wasted  in 
every  department.  In  order  to  be  specific  in  this  matter,  ii  may 
be  well  to  point  out  the  most  common  sources  of  waste,  so  that 
they  at  least  may  be  guarded  against. 

Waste  of  labor  depends  very  largely  upon  the  plan  of  con- 
struction of  the  institution  (this  will  be  discussed  in  connection 
with  the  various  illustrated   plans  in  this  work).     We  take,  for 


GENERAL  SUPPLIES  533 

instance,  the  item  of  delivering  the  food  to  all  patients  in  a  hos- 
pital of  a  stated  capacity;  the  amount  of  labor  involved  may  be 
from  two  to  ten  times  as  great  in  hospitals  variously  planned,  and 
which  contain  the  same  number  of  patients,  because  the  total 
amount  of  distance  to  which  the  food  lias  to  be  carried,  and  the 
provision  for  carrying  the  food  will  vary  to  tins  extent. 

The  matter  of  cleaning  floors,  walls  and  windows  may  imply 
a  waste  of  labor  in  a  hospital  not  planned  with  a  view  to  economy 
in  this  direction.  The  same  principle  applies  to  the  matter  of 
heating,  lighting  and  ventilation. 

DRUGS. 

In  reviewing  the  expense  of  unite  rials  consumed  we  very  fre- 
quently find  a  marked  amount  of  waste  in  the  item  of  drugs,  which 
usually  occurs  in  the  following  manner:  The  members  of  the 
staff  being  unfamiliar  with  the  cost  of  the  various  drugs  are  likely 
to  prescribe  the  more  expensive  article  in  case  two  remedies  of 
equal  value  are  considered,  largely  because  the  manufacturers  of 
the  more  expensive  remedies  have  taken  the  time  and  trouble  to 
thoroughly  advertise  their  products.  This  is  true  especially  of 
many  of  the  new  imported  remedies.  Many  of  these  cost  the  man- 
ufacturer scarcely  as  many  cents  per  ounce  as  they  receive  dollars 
per  ounce  when  they  are  sold  to  the  hospitals.  Being  patented, 
the  hospital  has  either  to  do  without  these  remedies,  or  they  niusi 
pay  the  enormous  prices  asked  for  them.  The  manner  in  which 
these  remedies  are  introduced  into  a  hospital  is  usually  so  well 
studied  that  unless  the  physician  comprehends  the  system  he  will 
scarcely  appreciate  that  he  has  been  duped  into  becoming  the 
means  by  which  this  waste  is  established  in  the  institution. 

In  order  to  give  this  point  practical  application  an  instance 
may  be  given  to  illustrate.  The  manufacturer  places  one  ounce 
of  a  valuable  tonic,  costing  not  to  exceed  three  cents,  in  a  twelve- 
ounce  bottle  with  four  ounces  of  whisky  worth  seven  cents,  and 
seven  ounces  of  elixir  worth  two  cents.  To  determine  the  merits 
of  this  remedy  he  supplies  to  the  institution,  free  of  charge,  one- 
half  a  gross  of  twelve-ounce  bottles.  The  patient  is  given  one- 
fourth  to  one-half  an  ounce  of  this  mixture  three  times  a  day.  and 
receives  the  tonic  effect.  In  this  manner  the  remedy  becomes  es- 
tablished. The  experiment  has  cost  the  manufacturer  less  than 
twelve  dollars,  but  as  a  result  the  staff  has  become  accustomed  to 
prescribe  the  remedy  in  a  routine  way.  As  soon  as  the  \'yco  sup- 
ply is  exhausted  the  hospital  begins  to  purchase  it  at  nine  dollars 
per  dozen  bottles,  which  is  more  than  six  times  the  actual  cost  of 
the  remedy.    No  one  concerned  appreciates  the  fad  that  an  item 


.":;  !  GENERAL  SUPPL]  ES 

of  waste  has  occurred,  and  yel  there  has  been  what  would  be  con- 
sidered in  any  other  enterprise  a  great  amount  of  waste. 

Another  source  of  waste  in  the  matter  of  drugs  comes  from 
the  faulty  system  of  prescribing  for  each  patient  a  given  quantity 
of  a  mixture,  and  then  giving  only  a  small  portion  of  it,  throwing 
away  the  remainder  because  the  exact  formula  might  not  be  suit- 
aide  for  any  other  patienl  in  the  near  future.  If  the  attention  of 
the  staff  is  directed  to  these  facts  this  source  of  loss  can  be  avoid- 
ed, but  unless  attention  is  given  the  matter  of  waste  will  amount 
to  at  least  one-half  of  the  drug  hill.  Xo  one  outside  of  the  mem- 
bers of  the  staff  can  possibly  prevent  this,  because  they  are  the 
only  ones  connected  with  the  institution  who  are  competent  to 
judge  of  the  value  of  remedies. 

There  is  a  Laudable  tendency  in  medical  men  employed  in  hos- 
pital practice  to  make  their  work  thoroughly  modern.  This  neces- 
sitates the  study  of  the  newer  remedies  in  their  clinical  applica- 
tion. The  younger  assistants  are  likely  to  be  especially  enthusi- 
astic over  these  observations,  and  as  a  result  many  expensive 
remedies  must  necessarily  be  tried.  So  long  as  these  observa- 
tions are  carefully  made  the  amount  of  benefit  usually  equals,  or 
exceeds,  the  harm  that  results.  Unfortunately  the  remedies  are 
likely  to  be  continued  in  use  long  after  their  uselessness  lias  been 
practically  demonstrated.  The  profit  to  the  manufacturer  is  so 
greal  thai  he  can  well  afford  to  push  the  remedies  systematically 
with  the  new  assistants  in  hospitals  where  there  is  rotation  in 
service.  It  is.  therefore,  worth  while  to  examine  the  shelves  in 
the  drug  rooms  in  hospitals  to  observe  the  number  of  these  reme- 
dies thai  accumulate,  and  members  of  hospital  staffs  should  bear 
these  thing's  in  mind,  as  a  large  amount  of  waste  may  be  eliminat- 
ed by  a  little  attention  to  these  details. 

FOOD. 

The  possibilities  of  waste  in  food  supplies  in  hospitals  is  very 
great,  especially  in  this  country.  In  European  countries  this  sub- 
ject has  been  thoroughly  studied.  The  degree  of  perfection  at- 
tained in  the  item  of  saving  food  in  private  families,  and  in  hotels 
there  has  reached  such  perfection  that  it  would  be  well  worth 
while  to  study  the  results  in  connection  with  this  item  of  waste  in 
our  hospitals.  The  importanl  point  to  be  gained  from  them  is 
the  conviction  that  practically  every  particle  of  food  purchased 
'••in  be  made  palatable  and  valuable  from  the  point  of  nutrition. 
I:,  this  country  milk,  which  should  constitute  a  Large  portion 

lie  r«>od  of  hospital  patients,  can  always  be  obtained  at  a  com- 
paratively smaM  expense.     It  is  also  possible  to  obtain  milk  of 


GENERAL  SUPPLIES  535 

excellent  quality,  if  the  source  of  supply  is  carefully  inspected. 
The  large  hospitals  should  obtain  all  of  their  milk  from  one  farm 
on  which  cows  have  been  carefully  tested  for  tuberculosis,  and 
where  the  manner  of  handling  the  milk  is  carefully  prescribed. 
The  feeding  of  the  cows,  the  water  supply,  the  cleanliness  and 
general  hygiene  of  the  stables,  should  all  be  under  strict  super- 
vision. Milk  cans  should  be  sterilized,  and  the  milk  scientifically 
cooled  and  preserved  in  a  separate  room  with  an  even  tempera- 
ture. This  will  be  described  later  in  connection  with  building 
plans.  The  milk  should  be  delivered  in  sealed  cans  to  1  lie  hos- 
pital. 

Having  provided  the  institution  with  a  good  quality  of  milk 
and  a  proper  place  for  storing  the  general  supply,  it  is  important 
to  provide  means  for  delivering  this  milk  in  a  wholesome  condi- 
tion to  the  patient.  It  is,  of  course,  impossible  for  the  nurse  to 
go  to  the  general  supply  room  for  every  glass  of  milk  used.  This 
would  make  it  possible  for  contamination  to  occur  between  the 
time  of  leaving  the  general  supply  room  and  delivering  it  to  the 
patient,  unless  provision  is  made  for  keeping  it  in  proper  refrig 
erators,  and  in  aseptic  receptacles  on  the  various  floors. 

If  the  milk  is  placed  in  the  same  refrigerator  with  ether  arti- 
cles of  food  it  will  soon  absorb  a  sufficient  amount  of  odor  from 
such  foods  to  make  it  unpalatable.  The  diet-kitchen  on  each  floor 
should  contain  a  sterilizer  sufficiently  large  to  permit  the  introduc- 
tion of  the  milk  cans  which  are  used  on  the  various  floors.  A.S 
soon  as  a  can  is  emptied  it  must  be  thoroughly  washed  ami  then 
boiled  for  twenty  minutes  in  a  solution  of  an  ounce  ^^'  baking 
soda  to  four  gallons  of  water.  They  are  then  well  rinsed  with 
boiling  water  and  placed  in  the  ice  box  to  cool  before  refilling.  If 
the  sterilizers  on  the  various  floors  are  not  large  enough  to  cod 
tain  these  cans,  they  should  then  be  carefully  washed  with  hoi 
water  and  soda,  then  filled  completely  with  boiling  wader  and  per 
mitted  to  stand  for  hall'  an  hour,  after  which  they  may  lie  deliv- 
ered to  the  general  supply  room,  where  they  should  be  sterilized 
and  cooled  before  they  are  used.  These  cans  should  be  made  of 
block  tin  to  prevent  them  from  rusting. 

Unless  these  precautions  are  taken  there  will  be  a  consider- 
able waste  in  the  milk  supply. 

Too  much  attention  cannol  be  given  to  the  milk  supply.  IT 
milk  is  wholesome  and  palatable  mosl  patients  wiTT  be  better  nour 
ished,  during  the  greater  portion  of  their  stay  in  the  hospital,  on 
a  milk  diet,  than  on  any  other  diet  that  may  be  devised.  It'  th«' 
milk  is  obtained  from  healthy  animals  which  have  been  properly 
fed  and  scientifically  cared  for,  it  is  sure  to  be  palatable  feo  many 


536  GENERAX,  SUPPLII  s 

patients  who  cannot  ordinarily  take  it.  And  it  is  of  great  impor- 
tance, manifestly,  to  give  careful  attention  to  the  matter  of  diet 
in  a  very  specific  way.  This  attention  should  be  given  by  a  per- 
son whose  judgment  is  good  in  such  matters,  and  by  one  who  can 
also  give  direct  supervision  to  the  matter  of  economy  in  connec- 
tion with  that  of  diet. 

With  these  two  points  carefully  watched  and  considered,  the 
patient  will  receive  the  food  that  is  best  for  him,  and  there  will 
be  no  unnecessary  waste. 

These  facts  apply  to  all  food  substances.  The  amount  of 
meat,  for  instance,  which  is  properly  used  in  feeding  a  giveD  num- 
ber of  patients  is  very  small;  there  is  scarcely  a  patient  who  can 
profitably  consume  more  than  one  or  two  ounces  of  meat  at  a 
meal.  If.  however,  this  patient  is  given  a  steak  weighing  half  a 
pound,  there  will  he  a  waste  of  three  hundred  per  cent,  and  the 
patient  will  not  be  as  well  satisfied  as  he  would  had  the  steak  been 
divided  in  four  portions  and  delicately  served  to  four  patients. 

The  same  is  true  of  all  other  foods:  a  small  amount  of  vege- 
table, a  thin  slice  of  bread,  will  be  far  more  acceptable  to  the  pa- 
tient, and  he  will  undoubtedly  get  more  nourishment  from  a  meal 
served  in  this  manner  than  he  would  were  he  offered  four  times 
the  amount. 

Food  should  be  delivered  hot  to  the  patient.  This  is  not  easy 
to  accomplish,  even  in  a  properly  constructed  and  well-managed 
institution,  but  it  can  be  done  if  the  importance  of  the  point  is 
fully  appreciated  by  those  in  charge  of  the  department.  This  is 
of  so  much  importance  to  the  prosperity  of  the  institution,  as  well 
;.-  to  the  comfort  of  the  patient,  that  it  may  be  well  to  reiterate  the 
advantages  to  lie  gained  from  serving  small  portions  of  daintily 
arranged,  hot,  and  therefore  attractive,  palatable  food.  The  pa- 
tient will  profit  by  being  tempted  to  eat  more;  he  will  better  digest 
a  meal  which  is  made  attractive  to  him,  and  will  consequently  get 
greater  benefit  from  it.  The  institution  will  benefit  from  the 
praise  given  it  by  well -satisfied,  enthusiastic  patients,  as  well  as 
from  the  materials  saved  in  this  department. 

SAVING  WASTE  MATERIALS. 

Each  new  patient  should,  of  course,  be  supplied  with  a  fresh 
piece  of  soap,  which  will  mean  a  great  many  small,  or  left-over, 
pieces.  All  of  these  should  be  saved  and  occasionally  boiled  up 
into  some  form  of  soft  soap  to  be  used  for  washing  rv  cleaning 
purposes. 

All   butter  and   fat    which   is   left   over  from  cooking  or  from 


GENERAL  SUPPLIES  537 

the  trays  can  be  utilized  in  making  soap  if  a  soap  machine  is  em- 
ployed. This  can  be  arranged  for  in  connection  with  the  laundry 
machine. 

It  would  be  useless  to  attempt  to  enumerate  all  the  details 
through  which  this  saving  of  waste  material  may  be  carried.  In 
the  housekeeping  department  the  opportunities  are  especially 
numerous;    the  few  instances  mentioned  will  serve  as  examples. 

SUKGICAL  DRESSINGS. 

The  prevention  of  waste  in  surgical  dressings  is  oue  of  the 
leading  items  in  hospital  management.  The  dangers  from  using 
over  again  dressing  materials  which  have  come  in  contact  with 
infected  wounds  are  so  great  that  the  natural  tendency  of  most 
surgeons  is  to  discard  everything  that  has  once  been  used;  and 
then  there  is  a  constant  tendency  to  make  dressings  unnecessarily 
large.  As  a  result  of  these  facts  a  system  of  waste  is  developed 
which  aggregates  much  more  in  most  institutions  than  the  amount 
actually  required  for  conducting  the  work  in  the  best  possible 
manner.  There  will  always  be  waste  here,, but  if  the  surgeons  in 
charge  will  give  reasonable  attention  the  amount  can  be  reduced 
to  a  minimum.  If,  however,  the  surgeon  himself  is  wasteful,  no 
admonition  to  the  assistants  in  the  department  will  be  of  benefit  in 
preventing  unnecessary  loss.  In  a  few  of  the  best  organized  hos- 
pitals in  the  country  a  great  amount  is  saved  by  sterilizing  over 
again  all  of  the  dressings  which  have  been  used  in  non-septic 
cases. 

If  all  dressings  are  delivered  from  a  central  supply  room  by 
a  competent  nurse  who  personally  superintends  their  sterilization, 
there  can  be  no  doubt  of  their  being  perfectly  safe  to  use  in  re- 
dressing septic  cases.  These  packages  of  dressings  should  be  cov- 
ered with  a  muslin  cover  sufficiently  thick  to  prevent  infection 
from  the  time  they  are  sterilized  until  they  are  used. 

SURGICAL  INSTRUMENTS. 

There  are  also  great  possibilities  of  waste  in  the  purchasing 
of  surgical  instruments,  in  which  there  are  two  different  systems 
used.  According  to  the  firs!  system  the  hospital  purchases  a  fan- 
supply  of  those  instruments  which  arc  constantly  used,  such  as 
dissecting  forceps,  hemostatic  forceps,  scalpels,  steel  sounds, 
probes,  retractors, scissors,  needles,  needle  holders,  chisels,  trocars, 
etc.  Later  on  as  special  instruments  are  required,  like  trephines. 
gastroenterostomy  clamps,  lithotritos.  these  also  are  obtained,  hi 
each  instance  the  simplest  form  of  instrument  is  chosen  because 
it  has  the  greatest  range  of  usefulness. 


538  GENERAL  SUPPLIES 

According  to  the  second  system  the  members  of  the  staff  se- 
ll ■<  t  instruments  that  might  be  required  to  cover  every  possible 
emergency  in  their  department.  They  also  supply  their  depart- 
ment with  everything  new  and  intricate  in  the  way  of  surgical 
instruments  and  appliances.  This  plan  will,  of  course,  furnish 
all  of  the  instruments  secured  under  the  first  system,  and  in  addi- 
tion a  large  number  which  are  ingeniously  planned  to  do  certain 
things  specially  well.  In  comparing  the  reports  of  two  institu- 
tions in  which  approximately  an  equal  amount  of  surgical  work 
i-  being  done,  the  cost  of  surgical  instruments  according  to  the 
second  system  is  nearly  twelve  times  as  great  as  the  amount  ex- 
pended  for  instruments  according  to  the  first  system. 

As  a  rule  the  quality  of  work  is  superior  in  the  institution 
using  the  simpler  form  of  appliances.  From  using  them  constantly 
the  surgeon  becomes  familiar  with  each  individual  instrument, 
and  is  consequently  able  to  reduce  the  amount  of  traumatism  to  a 
minimum. 

FUEL. 

The  waste  in  fuel  comes  chiefly  from  badly  planned  systems 
of  heating  and  ventilation.  These  systems  will,  of  course,  be  fully 
considered  later  on.  when  it  will  be  demonstrated  that  in  order  to 
secure  sufficient  ventilation  a  considerable  amount  of  heat  must 
be  wasted,  but  with  careful  attention  in  this  department  much  sav- 
ing can  be  accomplished,  where  ordinarily  much  is  lost.  One  sav- 
ing item  of  greal  importance  is  the  plan  of  having  steam  piped  from 
the  general  heating  plant  to  the  various  service  rooms  for  the  pur- 
pose of  sterilizing  and  heating  dishes,  for  cooking,  etc. 

Much  space  could  be  consumed  in  discussing  all  the  possible 
details  nt*  economy  in  the  various  departments,  but  it  seems  better 
to  point  out  the  possibilities  of  economy  in  a  general  way  in  order 
that  those  in  charge  of  these  departments  may  develop  syst< 
applicable  t<»  the  specific  conditions  under  which  they  exist. 


CHAPTER  XXVIII. 

HOSPITAL  FINANCES. 

It  is  of  the  greatest  importance  to  place  the  financial  end  of 
every  enterprise  upon  a  sound  basis  in  order  to  establish  perma- 
nence and  prosperity.  This  fact  becomes  more  important  as  the 
element  of  competition  is  introduced. 

An  institution  with  an  excellent  financial  system  must  have 
a  great  advantage  over  its  competitor  with  a  defective  system. 
The  difference  between  these  two  systems  is  not  so  apparent  in 
the  early  organization  of  an  institution  as  it  becomes  a  few  years 
later,  because  any  deficit  which  may  occur  at  the  end  of  the  year 
is  usually  disposed  of  by  a  suitable  donation  from  some  philan- 
thropic friend.  In  this  manner  the  work  for  the  following  year 
is  not  seriously  hampered  by  the  bad  financial  management  of  the 
one  preceding. 

Very  recently,  however,  there  has  been  a  change  in  the  meth- 
ods of  philanthropists;  many  of  them  now  take  the  precaution 
to  have  the  past  financial  management  of  an  institution  examined 
by  an  expert  before  supplying  funds  for  its  future  support.  This 
method  is  certain  to  become  generally  adopted,  and  consequently  it 
will  be  necessary  to  establish  reliable  systems  in  order  to  share 
in  the  contributions  from  these  public-spirited  citizens.  Instead 
of  apparent  philanthropy  this  will  develop  real  philanthropy,  and 
as  a  result  of  this  change  there  will  be  a  natural  selection  in  favor 
of  those  institutions  which  appreciate  this  step  in  advance,  and 
which  must  result  in  the  "survival  of  the  fittest." 

In  establishing  a  financial  system  the  firsl  stop  musl  I"'  in  the 
direction  of  a  simple  bu1  very  comprehensive  system  of  book- 
keeping. 

If  the  system  he  simple  any  fairly  educated  person  can  :»" 
taught  to  perform  the  work  perfectly,  ami  therefore  it  will  nol  be 
necessary  to  employ  an  expensive  bookkeeper.     If  the  system  is 

thoroughly  adapted  to  the  needs  of  the  institution  the   results  v.  ill 

be  quite  as  satisfactory  as  though   much  more  monej    wore  ex- 
pended in  this  service.     In  more  than  ninety  per  omit,  of  all  hos- 
pitals in  this  country  this  item  of  economy  is  of  real  importance. 
In    order   to    have    perfect    results    in    the    system,    two    points 


,-)4l  I  IK  ISPITAL  FI N A N C KS 

should  be  borne  in  mind— viz.,  the  person  keeping  the  books  must 
be  accurate  in  carrying  out  the  plan,  and  the  hooks  must  be  regu- 
larly audited  by  a  committee,  preferably  of  three  expert  bookkeep- 
ers who  are  independent  of  the  institution  and  are  not  members  of 
the  Board  of  Trustees. 

Accuracy  in  work  is  a  habit,  and  if  the  bookkeeper  does  not 
possess  this  habit  another  should  be  employed  who  does.  It  may 
even  be  necessary  to  make  a  number  of  changes  before  the  proper 
person  is  found,  but  it  is  possible  to  secure  the  right  person  with 
the  necessary  qualifications  at  a  salary  which  is  consistent  with 
the  financial  condition  of  the  institution  in  question. 

Every  institution  in  moderate  financial  circumstances  may 
have  among  its  friends  a  sufficient  number  of  expert  bookkeepers 
who  would  gladly  assist  in  auditing  the  books  of  the  hospital.  The 
income  of  these  bookkeepers  may  not  permit  them  to  give  finan- 
cial aid  to  the  institution,  but  by  giving  this  personal  service,  which 
is  in  itself  decidedly  valuable,  they  feel  that  they  have  been  help- 
ful toward  making  a  success  of  a  worthy  charity. 

In  the  large  and  wealthier  institutions  an  expert  accountant 
should  be  employed  to  audit  the  books  from  time  to  time. 

In  the  hospitals  on  the  continent  in  Europe  the  financial 
system  is  entirely  in  the  hands  of  the  authorities  of  the  govern- 
ment or  city,  and  there  is  consequently  in  vogue  a  system  which 
is  accurate,  although  in  many  instances  very  cumbersome. 

In  England  the  subjeci  of  hospital  finances  has  been  greatly 
developed,  especially  through  the  unceasing  activity  of  Sir  Henry 
C.  Burdett,  who  has  remarkable  ability  as  a  business  man,  has 
dealt  with  important  financial  questions  for  many  years,  and  is 
especially  fitted  to  organize  this  department  of  hospital  manage- 
ment. It  has  been  his  aim  for  years  to  establish  a  uniform  system 
for  all  hospitals  in  England  which  are  controlled  by  charitable 
organizations.  This  implies  for  these  institutions  a  uniform  sys- 
tem of  bookkeeping,  and  a  uniform  system  of  maintaining  records. 

It  is  difficult  to  make  a  comparative  study  of  the  annual  re- 
ports of  hospitals  iii  this  country  because  of  the  lack  of  uniformity 
in  keeping  records,  which  makes  it  quite  impossible  to  arrive  at 
any  fair  conclusions.  In  each  case  it  seems  to  be  the  object  of  the 
document  to  make  the  best  possible  showing  for  the  institution 
without  regard  to  the  methods  employed  to  obtain  such  results, 
and  without  following  any  definite  system  of  recording  the  facts 
upon  which  the  conclusions  are  based. 

A  committee  of  the  Association  of  American  Hospital  Superin- 
tendents has  made  a  careful  study  of  these  methods,  and  has  pro- 
duced what  may  be  taken  as  a  basis  for  a  system  which  can  be 


HOSPITAL  FINANCES  541 

generally  applied.  This  should  result  in  uniformity  in  the  mat- 
ter of  financial  reports  for  American  hospitals. 

This  committee  was  composed  of  some  of  the  most  experi- 
enced and  capable  hospital  men  in  the  country,  who  gave  a  greal 
amount  of  time  and  thought  to  the  study  of  this  subject,  and  con- 
sequently it  seciins  wise  to  incorporate  their  system  of  keeping 
uniform  hospital  records  in  this  work,  and  to  recomsuend  it  gen- 
erally to  hospital  authorities. 

There  are  many  reasons  why  this  plan  should  be  generally- 
adopted.  It  is  comprehensive  and  at  the  same  time  simple.  It  will 
facilitate  comparisons  between  the  various  institutions.  It  will 
establish  precedent  upon  an  accurate  basis.  It  will  eliminate  ap- 
parent and  substitute  real  results.  It  will  substitute  a  uniform 
system  devised  by  experts  for  systems  introduced  into  the  vari- 
ous institutions  by  amateurs. 

The  following  forms  here  introduced  have  been  adopted  by 
four  of  the  leading  hospitals  of  this  country  because  they  are  the 
results  of  careful  study  and  are  already  practically  in  use,  conse- 
quently they  are  beyond  the  experimental  stage.  This  plan  pro- 
vides comparative  reports  for  two  years.  If  preferred  the  reports 
for  three  years  could  be  introduced  for  comparison. 


542  HOSPITAL   FINANCES 


SCHEDULE  U 
Detailed   Statement  of  Operating,   Corporation   and 
Other  Current  Expenses* 


Administration  Expenses  : 

1906.  1905. 

Salaries,  Officers  and  Clerks 

Office  Expenses 

Stationery,  Printing  and  Postage 

Telephone  and  Telegraph 

Legal  Expenses _ 

Miscellaneous 

Total  Administration  Expenses. 

Professional  Care  of  Patients  : 
Salaries  and  Wages  : 

Physicians.  • 

Supt.    of    Nurses,    Assistant   and    In- 
structors          

Nurses 

Special  Nurses 

Orderlies 

Special    Orderlies 

Ward   Employees 

Eqi  [PMENT  FOR  NURSES: 

Uniforms 

Books 

Instruments 

Medical  and  Surgical  Supplies; 

Apparatus  and  Instruments 

Medical    Supplies 

Surgical  Supplies 

Alcohol,   Liquors.  Wines,  etc 

Dispensary;  Salaries  and  Labor 

Supplies 

Emergency   Ward:  Salaries  and  Labor 


Supplies. 


Visiting  and  Homej        Salaries 

(District)  Nursing]        Supplies 

Total  Professional  Care  of  Patients. 


Department  Expenses 

Ambulance  :  Labor 

Supplies 


Pathological        \  Salaries  and  Labor. 


Laboratory:        }  Supplies 

Training  School  :  Salaries  and  Labor. 

Supplies 

Housekeeping.  Labor  

Supplies 

Kitchen:  Labor. .". 

Supplies 

Laundry:  Labor 


Supplies. 


HOSPITAL   FINANCES  543 


SCHEDULE    I -Continued. 
Department   Expenses — Continued: 

1906.  '905. 

Steward's  Department: 

Labor 

Provisions: 

Bread -•■■ 

Milk  and  Cream 

Groceries 

Butter  and  Egga 

Fruits  and  Vegetables 

Meat,  Poultry  and  Fish _ mmmm __ _ 

Total  Steward's  Department ^__^ 

Total  Department  Expenses 

General  House  and  Property  Expenses : 

Electric  Lighting 

Fuel,  Od  and  Waste 

Gas - 

Ice 

Insurance 

Maintenance,  Real  Estate  and  Buildings 

Maintenance,  Machinery  and  Tools 

Plumbing  and  Steam  Fitting 

Photography - 

Rent 

Miscellaneous  —        ^^^.^^miim         ____— . 

Total  General  House  and  PropertyExp        ^__^__         ^^__^ 

Total  Operating  Expenses 


Corporation  or  Other  Current  Expenses  : 

Salaries,  Officers  and  Clerks  

Stationery,  Printing  and  Postage 

Legal    Expenses 

Interest  on  Mortgages  or  Loans  Payable 

Taxes 

Miscellaneous 

Total  Corporation   Expenses 

Current  Expenses  from   Special   Funds  for 

Stated  Purposes: 
(Show  expenditure  from  each  fund  separately.) 


Grand  Total  Current  Expenses 

Excess  of  Current  Revenue  over  Current  Exps 
Total 


544  HOSPITAL  FIN  \N<  ES 


SCHEDULE  2. 
Detailed  Statement  of  Current   Revenue, 


Hospital  Receipts : 

(or  Operating  Receipts.) 

1906.  1005. 

Private  Room  Patients _ _ 

Hoard  of  Friends  of  Patients _ _     _         

Ward  Pay  Patients 

Special  Nursing _         _ _. 

Dispensary _ 

Emergency  Ward _ _ 

Ambulance  Fees _ _ 

Miscellaneous 

Total  Hospital  Receipts 

Other  Revenue  or  Income : 

From  the  Public  Treasury _ _ 

Donations   from    Individuals   to    meet    Cur- 
rent Expenses 

Donations  from  Churches  to   meet    Current 

Expenses _ __ _ 

From  Hospital  Saturday  and  Sunday  Ass'n 

Net  Receipts   from   Entertainments,     Fairs, 
Fetes,  etc 

Legacies,    unrestricted 

Profits  on  Investments  sold _ 

Revenue   from    Investments    or    Funds    for 
Current  Use 

Miscellaneous „ 

Total  Other  Revenue  or  Income 


Income   from    Special    Funds    for    Current 

Expenses: 
(Show  income  account  each  fund  separately.) 


Grand  Total  Current  Revenue 

Excess  Current  Expenses  over  Current  Rev- 
enue  _ _ 

Total _ „ 


HOSP1TA  L  I "  1  N  A  N  CES  545 

SCHEDULE  3. 

Summary   of   Financial   Transactions   for    the   Year  Ended 
September   30,    1906. 


Capital   Expenditures: 

Additions  to  Sites  and  Grounds  

Additions  and  Betterments,  Buildings 

Furniture  and  Fixtures  (If  chgd.  to  Capital 

Acct.) 

New  Machinery  (If  chgd.  to  Capital  Acct.) 

Apparatus  and  Instruments,  do. 
Ambulances,  Live  Stock,  etc.,  do. 
Miscellaneous 


1906.  1905. 


Total  Capital  Expenditures 

Surplus  Account: 

Grand  Total  Current  Expenses,   Schedule  1. 

Loss  and  Depreciation 

(Show  items  separately  if  desired.) 

Total 

Surplus  for  the  year 

Total 


SCHEDULE  3. 

Summary  of  Financial  Transactions  for  Year  Ended 
September  30,  J 906. 


Capital    Receipts  : 

Fully  Endowed  Beds  

Partly  Endowed  Beds 

General  or  Special  Funds  or  Gifts  for  other 

than  Current  Expenses 

(Show   receipts   account   each   fund    or   gift 

separately.) 

Total  Capital  Receipts. 


Deficit   Account : 

Grand  Total  Current  Revenue,  Scheduie  2... 
Amount  charged  off   Endowed  Bed  Fund  or 

other  Fund  Reserves  account  liability 

of  Hospital  having  ceased 

Total 

Deficit  for  the  Year 

Total 


1906.  1905. 


54G  HOSPITAL  FINANCES 


SCHEDULE  4. 

Comparative  Balance  Sheet  for  Years  Ended 

September  30th,  J 906  and  J  905. 


Capital  Assets: 


HosriTAL  Properties  and  Equipments: 

1906  1905  Increase.    Decrease. 

Sites  and  Grounds _ 

Buildings  

Furniture  and  Fixtures 

Machinery  and  Tools 

Apparatus  and  Instruments , 

Ambulances,  Live  Stock,  etc.     

Miscellaneous 


Investments: 

Mortgages  Receivable 

Bonds 

Stocks 

Other  Investments _ 

Total  Capital  Assets 


Current  Assets' 


Loans  and  Notes  Receivable    

Accounts  Receivable 

Accounts  Receivaolefrom  Public 

Treasury _... 

General  Material  on  Hand 

Cash  in  hands  of  Treasurer 

Cash  in  hands  of  Superintendent 
Advances: 

Prepaid  Insurance 

Other  Prepaid  Expenses _ 

Total  Current  Assets   ... 

Grand  Total  Assets 

Deficit   

Total 


HOSPITAL  FINANCES 


:»4  7 


SCHEDULE  4. 

Comparative   Balance   Sheet   for   Years  Ended 
September  30th,  1906  and  \ 905. 


Capital  Account  (Hospital  Prop- 
erties and  Equipments) 

Endowed  Bed  Fund  Reserves... 

Pai  tly  Endowed  Bed  Fund  Re- 
serves   

Other  Fund  Reserves 

(List  each  separately  ) 


Bonds  Outstanding  on   Hospital 

Property 

Mortgages  Payable 

Total  Capital  Liabilities 


Capital    Liabilities: 

1906  '905 


Increase.    Decrease 


Current  Liabilities: 


Loans  and  Notes  Payable 

Audited    Vouchers     Unpaid    or 
Accounts  Payable  

Total  Current  Liabilities  ... 
Grand  Total  Liabilities 

Surplus.. 
Total 


54S 


HOSPITAL  Fl  N  A  N  t  ES 


O 


6 

•S 

3 

Q 


c 

3 


bo 

o 

— 

C 

I 

■*-• 

*S 

*■• 

00 


Decrease. 

Increase. 

■ 

1 

Amount 
Sept.  30,  1906. 

Expended 

During  Year. 

Received 

During  Year. 

-     Z 
X    cl 

C 

Description  of  Funds. 

• 

< 

h 

O 

HOSPITAL  FINANCES  549 

SCHEDULE  6. 
Comparative  Statistics  for  Years  Ended  September  30,  1906  and  J  905 

Hospital  Wards  and  Private  Rooms. 

1906  1905 

Patients  in  Hospital  First  of  Year: 

In  Medical  Wards,  Male  

Female 

In  Surgical  Wards,  Male   

Female 

In  Private  Rooms,  Male. , 

Female  

Total ....... 

Patients  Admitted  During  Year: 

To  Medical  Wards,  Male 

Female 

To  Surgical  Wards,  Male  

Female 

To  Private  Rooms,  Male 

Female 

Total. 

Total  Patients  Treated  in  Hospital  Wards 
and  Privaie  Rooms  During  Year 

Male 

Female 

Patiknis  Discharged  During  Yeak: 

Cured •. 

Improved 

Unimproved 

Transferred  to  other  institutions  _ 

Died 

Total 

Patients  in  Hospital  End  of  Year: 

In  Medical  Wards,  xVIale.  

Female 

In  Surgical  Wards,  Male 

Female 

•    In  Private  Rooms,   Male 

Female 

Total 

Total  Patient  Days  Treatment: 

Free  Ward 

Endowed    Bed 

Pay   Ward 

Private  Room ^^__^ 

Total 

Percentage: 

Free  Ward  Days 

Endowed  Bed  Days 

Pay  Ward  Days 

Private  Room  Days 

Average  Patients  per  Day: 

Free   Ward 

Endowed  Bed _ 

Pay  Ward 

Private  Room _^^^  

Total 

Average  Time  per  Patient  in  Hospital 

Daily  Average  Cost  per  Private  Room  Patient  _ _ 

Daily  Average  Cost  per  Ward  Patient  


550  HOSPITAL  FINANCES 


SCHEDULE   6- -Continued. 

1906.  *9°5- 


Emergency    Ward. 


Patients  Under  Treatment  first  of  year,  Male  „. 

Female    -.— 

Patients  Admitted  during  year,  Male  

Female 

Total  Patients  Treated -during  year,         Male         „. 

Female 

Patients  Discharged  during  year, 

Patients  Under  Treatment  end  of  year.  Male         

Female 

Visits  made  to  Emergency  Ward  timing  year,  

Average  Visits  made  per  day.  

Average  Visits  per  Patient  

Daily    Average   Cost   per    Emergency    Ward 

Patient. 

Dispensary. 

tils  Under  Treatment  first  of  year,  Male         

Female     

Patients  Admitted  during  year,  Male         

Female     

Total  Patients  Treated  during  year,         Male         

Female    

Patients  Discharged  during  year. 

Patients  Under  Treatment  end  of  year,  Male  ... 

Female    

Visits  made  to  Dispensary  during  year,  

Average  Visits  per  day.  

Average  Visits  per  Patient  

Daily  Average  Cost  per  Dispensary  Patient 

Ambulance. 

Ambulance  Calls  during  year  

Average  Calls  per  day  

Average  Cost  per  Ambulance  Call  

Patients   Treated    by    Ambulance   Surgeon 

in  Emergency  Ward  and  Transferred  

Patients    Treated    by    Ambulance     Surgeon 

and  left  at  place  of  call  or   transferred 

direct  to  1  ither  Institutions 

Visiting   or    Home     District)    Nursing 

No.  of  Patii  nts  Visited  _  

No.  of  Visits  Made 

Average  Visits  per  d  

Average  cost  per  visit  

Summary. 

:    Patients    Treated    during    year  in  all 

Departments 

Average  Patients  per  day  in  all  Departments 

Daily  average  number  of  E  Hoarded 

in  Hospital     

Daily  Cost  per  capita  for    Provisions    for   all 

rted 


HOSPITAL  FINANCES  551 

INSTRUCTIONS    REGARDING    DISTRIBUTION    OF    HOSPITAL    OPERATING,    AND 

CORPORATION   OR  OTHER  CURRENT  EXPENSES. 

ADMIN]  STRA  TIO  X    EX  I '  E  X  S  ES. 

1.  Salaries,  Officers  and  Clerks. 

This  account  includes  the  salaries  of  general  officers  of  the 
hospital  and  their  assistants  or  clerks,  whose  salaries  are  not  di- 
rectly chargeable  to  any  department. 

This  account  should  not  include  salaries  of  officers  or  clerks 
who  are  exclusively  engaged  with  the  management  of  the  cor- 
poration, estate  or  sources  of  revenue  outside  of  the  ordinary  re- 
ceipts of  the  hospital  proper.  If  certain  officers  or  clerks  are 
partly  engaged  in  this  manner,  a  proper  proportion  of  their  sal- 
aries should  be  charged  accordingly. 

2.  Office  Expenses. 

This  account  includes  the  cost  of  traveling  expenses  of  em- 
ployes, car  fares,  express  charges,  messenger  service,  subscrip- 
tions to  newspapers  and  periodicals,  office  furniture  and  fixtures, 
and  such  other  office  supplies  as  are  not  properly  chargeable  to 
any  other  subdivisions  of  administration  expenses  or  to  corpora- 
tion expenses. 

3.  Stationery,  Printing  and  Postage. 

This  account  includes  the  cost  of  printing  annual  reports, 
blank  books,  blank  forms,  paper,  stationery,  stationery  supplies-, 
etc.,  used  in  the  general  work  of  the  hospital.  It  should  not  include 
expenditures  of  this  nature  made  for  corporation  purposes. 

4.  Telegraph  and  Telephone. 

This  account  includes  all  expenditures,  account  telegraph 
messages,  rent  of  telephones,  salaries  of  operators  or  maintenance 
of  telephones  and  telephone  lines. 

5.  Legal  Expenses. 

This  account  includes  all  fees  and  retainer,  paid  for  services 
of  attorneys,  costs  of  suits  and  all  legal  and  court  expenses  in- 
curred in  the  operation  of  the  hospital.  Il  should  not  include  ex- 
penditures of  this  nature  made  for  corporation  purposes. 

6.  Miscellaneous. 

This  account  includes  such  oilier  administration  expenses  as 
are  not  directly  chargeable  to  any  of  the  foregoing  account-,  or  to 
corporation  expenses. 

PROFESSION  \l.  CAM'.  OF   l\\  I  i  l.N  Is. 

7.  Salaries  and  Wages. 

This  account  includes  the  salaries  and  wages  of  employes 
under  the  various  headings  named. 

8.  Equipment  for  Nurses. 


~h)'2  HOSPITAL   FINANCES 

This  account  includes  the  cost  of  uniforms,  hooks  and  instru- 
ments, if  furnished  to  the  nurses  by  the  hospital. 

II'  uniforms,  books  and  instruments  arc  purchased  by  the  hos- 
pital, to  be  paid  for  later  by  the  uurses,  they  should  he  charged  to 
the  genera]  materia]  account,  and  that  account  should  be  credited 
when  these  are  paid  for  by  the  nurses. 

9.  Medical  and  Surgical  Supplies. 

This  account  includes  the  cost  of  apparatus  and  instruments, 
medical  and  surgical  supplies,  and  alcohol,  Liquors,  wines,  etc., 
purchased  for  the  genera]  use  of  the  hospital,  not  specifically 
chargeable  to  any  department. 

It  would  not,  however,  inclunde  the  purchase  of  apparatus  and 
instruments  in  Large  quantities  to  equip  new  and  additional  build- 
ings, which  should  he  charged  to  capital  account,  under  the  head- 
ing provided  therefor. 

10.  Dispensary. 

I  a  >  Salaries  and  LaUnv.  This  account  includes  the  salaries 
and  wages  of  physicians,  assistants,  nurses  and  any  other  em- 
ployes in  this  department. 

( b)     Supplies.     This  account    includes   the  cost   of  all   appa- 
ratus and   instruments,  medical   and   surgical   supplies,  and     any 
other  supplies  whatsoever,  which  are  properly  chargeable  to  this 
department. 
//.     Emergency  Ward. 

(a)  Salaries  and  Labor.  "Phis  account  includes  the  salaries 
and  wages  of  physicians,  assistants,  nurses  and  any  other  em- 
ployes in  this  department. 

( h )     Supplies.    This  account  includes  the  cost  of  all  apparatus 
and  instruments,  medical  and  surgical  supplies  and  any  other  sup- 
plies whatsoever,  which  are  properly  chargeable  to  this  depart- 
ment. 
12.     Visiting  or  Home  (District)  Nursing. 

( it  j  Salaries.  This  account  includes  the  salaries  of  nurses 
employed  in  this  service. 

(b)  Supplies  This  accounl  includes  the  cost  of  all  medical 
ami  surgical  supplies,  food,  clothing,  or  any  other  supplies  what  - 
soever  purchased  \'^v  this  service  for  use  of  patients. 

DEPARTMENT   EXPENSES. 

/.v.     Ambulance. 

(a  I  Labor.  This  account  includes  the  wages  of  all  employes 
in  this  department;  also  the  cosl  of  any  other  Labor  in  connection 
with  making  repairs  or  maintaining  the  equipment  of  this  depart- 
ment. 


HOSPITAL  FINAN<  ES  553 

(b)  Supplies.  This  account  includes  the  cost  of  all  equip- 
ment and  supplies  of  any  nature  which  are  properly  chargeable 
to  this  department;  also,  the  cosl  of  any  materia]  used  in  making 
repairs  or  maintaining  the  equipment  of  this  (Jepartment.  It 
should  not  include,  however,  new  and  additional  equipment,  such 
as  ambulances,  live  stock,  etc. 

It  is  considered  more  proper  to  charge  such  new  equipment  to 
capital  account,  under  the  heading  provided  therefor. 

14.  Pathological  Laboratory. 

(a)  Salaries  and  Labor.  This  account  includes  the  salaries 
and  wages  of  physicians,  assistants  and  any  other  employes  in  this 
department,  including  amounts  paid  for  cost  of  labor  in  making 
repairs  or  maintaining  the  equipment  of  this  department. 

(b)  Supplies.  This  account  includes  the  cost  of  all  appa- 
ratus and  instruments,  medical  and  surgical  supplies,  and  any  oth- 
er supplies  whatsoever,  which  are  properly  chargeable  to  this  de- 
partment; also,  the  cost  of  any  materials  used  in  making  repairs 
or  maintaining  the  equipment  of  this  department. 

15.  Training  School. 

(a)  Salaries  and  Labor.  This  account  includes  the  salaries 
and  wages  of  officers,  instructors,  and  any  other  employes  which 
are  chargeable  exclusively  to  the  cost  of  operating  and  maintain- 
ing the  training  school,  and  which  cannot  properly  be  charged  to 
any  other  account. 

( h )  Supplies.  This  account  includes  the  cost  of  supplies 
and  materials  which  are  directly  chargeable  to  the  cosl  of  operal 
ing  and  maintaining  the  training  school  exclusively,  but  dees  not  in- 
clude the  cost  of  supplies  for  housekeeping,  kitchen,  laundry,  stew- 
ard's department,  and  general  house  and  property  expenses  in  con- 
nection with  the  training  school,  which  should  he  charged  under 
their  respective  headings  elsewhere,  together  with  other  expenses 
of  similar  character  for  the  general  hospital,  as  it  does  not  seem  de 
sirable  to  further  subdivide  the  training  school  account. 

16.  Housekeeping. 

(a)  Labor.  This  account  includes  the  salaries  and  wages  <»!' 
the  housekeeper  and  all  persons  employed  in  this  department,  in- 
cluding waitresses,  chambermaids,  scrubwomen,  porters,  etc.,  etc.; 
also,  all  persons  employed  in  making  and  maintaining  housekeep- 
ing supplies  ami  in  cleaning,  etc.,  chargeable  to  the  general  hos- 
pital and  training  school,  and  qoI  chargeable  to  any  other  depart 
nient. 

(b)  Supplies.  This  account  includes  the  cost  of  furniture 
and  fixtures,  such  as  beds,  bedding,  chairs,  tables,  tableware,  Linen, 
and  all  other  housekeeping  supplies.     It  also  includes  the  repairs 


554  hospital  finan< ies 

of  same.     It  should  not  include,  however,  large  quantities  of  new 
and  additional  furniture. 

it  is  considered  more  proper  to  charge  these  to  capital  ac- 
count, under  the  beading  provided  therefor. 

17.  Kitchen. 

(a)  Labor.  This  accounl  includes  wages  and  labor  of  all 
persons  employed  in  tins  departnu  at,  in  connection  with  the  prep- 
aration and  general  distribution  of  all  food. 

(b)  Supplies.  This  account  includes  the  cost,  of  all  kitchen 
utensils,  fuel  used  in  the  kitchen  range  and  other  supplies  and 
materials  chargeable  to  the  operation  and  maintenance  of  the 
kitchen,  not  including,  however,  provisions  mentioned  under  the 
heading  of  steward's  department. 

18.  La  a  n<h;i. 

(a)  Labor.  This  account  includes  the  wages  of  employes 
engaged  in  this  department  or  the  cost  of  laundry  work  done  out- 
side. It  also  includes  th<  cost  of  any  labor  in  connection  with  re- 
pairs or  maintenance  of  equipment  of  this  department. 

(It)  Supplies.  This  accounl  includes  the  cost  of  all  supplies 
used  in  this  department,  including  the  materials  used  in  connec- 
tion with  operating  and  maintaining  the  equipment  of  this  depart- 
ment. 

19.  Steward's  Department, 

(a)  Labor.  This  account  includes  the  wages  of  all  persons 
employed  in  receiving,  storing  and  distributing  the  supplies  of  this 
department. 

(b).     Provisions. 

Bread — This  account  includes  the  cost  of  all  bread,  cake,  pas- 
try, etc..  purchased. 

Milk  ami  ('ream.  This  account  includes  the  cost  of  all  milk, 
cream,  cheese  and  ice  cream  purchased. 

Groceries.-  This  accounl  includes  the  cost  of  all  groceries, 
canned  goods,  llour,  dried  fruit,  etc. 

Butter  and  Eggs.  This  account  includes  the  cost  of  all  butter 
and  eggs. 

Fruits  and  Vegetables.  This  account  includes  the  cost  of  all 
fresh  fruits  and  fresh  vegetables. 

Meat,  Poultry  and  fish.  This  account  includes  ihe  cost  of  all 
meat,  whether  fresh,  dried  or  smoked,  ami  oJ  poultry,  game,  fish, 
and  all  sea  food. 

GENERAL    HOUSE    AND    PROPE11T1     EXPENSES. 

20.  Electric  Lighting. 

This  account    includes  the  cosl   of  all   labor,  supplies  and  ina- 


HOSPITAL   FINANCES  •>•••> 

terials  used  in  connection  with  operating  and  maintaining  the  elec- 
tric lighting  plant,  not  including,  however,  the  cost  of  maintaining 
machinery  used  in  connection  with  same,  which  is  chargeable  to 
maintenance,  machinery  and  tools.  It  includes  the  cosl  of  main- 
taining electric  lamps,  fixtures  or  wiring,  but  does  not  include  the 
cost  of  operating  steam  plant  or  dynamos,  which  is  chargeable  to 
maintenance,  machinery  and  tools.  This  account  of*  electric  light- 
ing includes  the  cost  of  any  electric  light,  if  furnished  from  outside 

21.  Fuel,  Oil  and  Waste. 

This  account  includes  the  cost  of  all  fuel,  oil  and  waste  used 
in  connection  with  operating  and  maintainig  the  power,  lighting 
and  heating  plant,  but  does  not  include  the  cost  of  fuel  used  in  the 
kitchen  or  laundry  range. 

22.  Gas. 

This  account  includes  the  cost  of  all  gas. 

23.  Ice. 

This  account  includes  the  cost  of  all  ice. 

(If  refrigerating  plant  is  used,  indicate  by  tool  note.) 

24.  Maintenance  Real  Estate  and  Buildings. 

This  account  includes  the  cost  of  all  labor  and  materials  used 
in  connection  with  repairs  and  maintenance  of  real  estate  and 
buildings  in  the  hospital  group.  It  includes  the  cost  of  repairs  to 
fences,  sidewalks,  and  the  cost  of  keeping  sidewalks  and  grounds 
in  good  order,  shoveling  snow,  etc. 

This  account  should  not  be  charged  with  repairs  and  renewals 
of  furniture  and  fixtures,  such  as  beds,  bedding,  chairs,  tables, 
tableware,  etc.,  which  are  chargeable  to  housekeeping  supplies. 

This  account  does  not  include  the  cost  of  new  and  additional 
real  estate  and  buildings.  It  is  thought  more  proper  to  charge  the 
cost  of  these  to  capital  account,  under  headings  provided  Poi  sites 
and  grounds  or  buildings. 

25.  Maintenance,  Machinery  and  Tods. 

This  account  includes  the  cost  of  all  labor  or  materials  u^<><\ 
in  connection  with  repairs,  maintenance  and   renewals  of  boilers 
stationary  engines,  dynamos,  pumps  and  other  machinery,  includ- 
ing the  shafting,  belting  and  other  appliances  for  running  m.ichin 
ery  and  all  tools  and  fixtures  used  in  connection  therewith 

It  includes  the  wages  iA'  engineers,  firemen,  etc..  not  directlj 
chargeable  to  other  accounts. 

This  account  should  not  include  the  cost  of  machinery  for  new 
buildings.  It  is  considered  that  this  is  more  properly  chargeable 
to  this  heading  under  capital  account. 

26.  Plumbing  and  Sham  Fitting. 

This  account  includes  the  cost  ol  all  labor  and  materials  used 


556  HOSPITAL  FINANCES 

in  connection  with  repairs  and  renewals  of  all  water,  gas  <>r  steam 
pipes  and  linings. 

27.  Photography. 

This  account  Includes  the  cost  of  all  Labor  and  materials  used 
in  the  X-ray  departmenl  or  other  photographic  work  or  supplies. 

28.  Rent. 

This  account  Includes  the  cost  of  rental  of  buildings  used  in 
connection  with  hospital  work. 

29.  Insurance. 

Thi>  account  includes  the  cost  of  all  insurance  for  account  of 
the  hospital. 

30.  Miscellani  ous. 

This  account  includes  the  cost  of  any  labor  and  materials 
chargeable  to  general  house  and  property  expenses,  not  included  in 
any  of  the  headings  already  provided  for. 

I  0RPORATION   OR  OTHER   CURRENT   EXPENSES. 

31.  Salaries,  Officers  and  Clerks. 

This  account  includes  salaries  of  officers  and  clerks,  who  are 
exclusively  engaged  with  the  management  of  the  corporation,  es- 
tate or  other  sources  of  revenue  outside  of  the  ordinary  receipts 
of  the  liospital  proper. 

Tf  certain  officers  or  clerks  are  partly  engaged  in  this  manner 
a  proper  proportion  of  their  salaries  should  be  charged  accord- 
ingly. 

32.  Stationery,  Printing  and  Postage. 

This  Mi-count  includes  expenditures  of  this  nature  for  cor- 
poration purposes,  including  soliciting  donations,  etc. 

33.  Legal  Expenses. 

This  account  includes  expenditures  of  this  nature  made  for 
corporation  purpose-. 

34.  I  nit  rest  on  Mortgages  and  Loans  Payable. 
This  heading  explains  itself. 

35.  Taxes. 

This  account  includes  all  taxes  paid  on  property  owned  by  the 
hospital  for  investment. 

36.  Miscellaneous. 

To  this  account  should  be  charged  any  other  corporation  or 
current  expenses  not  properly  chargeable  to  any  of  the  other  head- 
ings provided. 

37.  Current  Expenses  from  Special  Funds  for  Stated  Purposes. 
(Show  expenditure  from  each  fund  separately.) 

This  accounl  explains  itself. 


HOSl  LTAL  !  1XAN(  ES  00i 

BOOKKEEPING. 

In  order  to  establish  uniformity  in  bookkeeping  it  is  proper 
to  select  the  least  complicated  and  most  comprehensive  plan  which 
has  been  in  actual  use  in  hospitals  whoso  officers  have  kindly  fur- 
nished the  necessary  data. 

This  system  contains  the  following  books. 

Cash  Book. 

Journal. 

Invoice  Book. 

General  Ledger. 

Patients. 

Patients'  Register. 

CHARITY  ACCOUNTS. 

There  should  be  a  definite  system  of  bookkeeping  introduced 
in  connection  with  funds  contributed  for  charitable  purposes. 

A  ledger  should  be  kept  showing  the  amounts  credited  and 
charged  to  tlje  various  accounts,  and  a  report  should  be  made  at 
the  end  of  the  year  stating  exactly  what  had  been  done  with  the 
money  contributed  by  the  various  individuals  and  organizations. 
This  is    important     especially   in   institutions    supported    by 
church  organizations.    For  instance,  a  given  church  has  contribut- 
ed one  hundred  dollars  toward  the  support  of  the  hospital;  there- 
fore its  account  should  be  credited  with  this  amount.     Then,  the 
congregation  sends  a  charity  patient  to  the  hospital  for  twenty 
days  at  an  expense  to  the  hospital  of  $1.25  per  day.     The  amount 
of  twenty-five  dollars  should  be  charged  against  the  account.     At 
the  end  of  the  year  a  statement  should  be  sent  to  tins  particular 
church   setting  forth  the  condition  of  its   account.     Such    state- 
ment should  contain  the  name,  address,  occupation  and  age  ol   the 
patient    by  whom  sent,  the  condition  for  the  relief  ot   which  the 
patient  entered  the  hospital,  the  department  in  winch  the  patient 
was  treated,  and  the  condition  of  the  patient  when  discharged.     Lt 
might  be  better  to  substitute  for  the  name  and  address  the  number 
of  the  case  history  through  which  the  identity  of  the  patient  could 
be  established  by  referring  to  the  records  in  the  office  ot  the  hos- 
pital     The  important   point,  however,  is  to  give  the  donor  ol    the 
contribution 'an  opportunity  to  see  whal  good  had  actually  been 
accomplished  with  his  money,  which  will  ad  as  an  incentive  to  lur 
ther  financial  support  for  the  institution.     At  the  same  time  the 
authorities  at  the  hospital  will  be  compelled  to  make  a  dired  rec- 
ord 0f  every  case  for  which  money  has  been  expended,  and  they 
will  have  to  charge  a  definite  amount  to  a  definite  account. 


558  HOSPITAL  FINANCES 

The  following  two  forms  will  give  a  clear  idea  of  the  impres- 
sion their  use  will  make  upon  one's  miml.  Each  form  represents 
a  donation  of  one  hundred  dollars.  Each  donor  presumably  sup- 
poses that  lie  lias  done  one  hundred  dollars'  worth  of  good  by 
contributing  this  amount  to  the  hospital.  As  a  resuli  of  this  dona- 
tion, donor  number  one  finds  that  four  persons  have  been  restored 
to  health  and  thus  enabled  to  support  themselves  and  their  fam- 
ilies. There  has  been  supplied  to  them  such  care  and  treatment  as 
could  not  have  been  secured  in  their  own  homes,  not  having  the 
means  with  which  to  employ  trained  nurses;  neither  could  they 
afford  the  services  of  skilled  physicians  and  surgeons,  without 
which  service  one  or  two  of  them  at  least  mighl  not  have  recov- 
ered. The  community  at  Large  is  benefited  because  of  the  restora- 
tion to  full  working  capacity  of  useful  members  of  society. 

FORM  5. 
STATEMENT. 

Chicago 1906. 

M 


In  ace  Hint  with   Hospital. 

Charity  Fund. 

Jan.       1  —  By  cash  donation   $100.00 

Mar.     8 — To  21  days'  hospital  care  at  $1.50.  case  Xo $  31.50 

I  tousewife,  pneumonia. 
.Mar.     12 — To  7  days5  hospital  care,  children's  ward,  at  $1  .  .        7.00 

Acute  enteritis,  case   Xo. 
July      8 — To  35  da)  s'  hospital  care,  at  $1.50,  case  No 9    52-50 

I '.rick  carrier,  fractured  leg. 
\ug.  lj — To  (>  daws'  hospital  care,  at  Si. 50.  case  Mo 0.00 

Tailor,   infected   hand. 
\o\.  10 — To  5  days'  hospital  care,  at  Si. 50,  case   Xo 7.50 

Machinist.      Fractured  arm.  patient  returns  t  1 
out   patient  department. 


$  07.3.'' 
For  dressings   S     _> .  5  1 


Si  00.00     $100.00 


HOSPITAL  FINANCES  559 

FORM  6. 

STATEMENT. 

Chicago,   1006. 


M, 


In  account  with   Hospital. 

Charity  Fund. 

Jan.       1 — By  cash,  donation   $100.00 

Mar.     8 — To  20  days'  hospital  care,  at  $1.50,  case  No $  30.00 

Unemployed  vagrant. 
April    6 — To  18  days'  hospital  care,  at  $1.50,  case  Xo 27.00 

Acute  alcoholism. 
June  10 — To  6  days'  hospital  care,  at  $1.50,  case  Xo 

Contusion  of  head  with  seal])  wounds  saloon 

brawl    9.00 

Oct.      5 — To  22  days'  hospital  care,  at  $1.50,  case  Xo 33-00 

Crushing  injury,  tramp  ; 

Railroad  injury,  riding  on  bumper. 


$  99.00 
Balance    $     1.00 


$100.00     $100.00 

Form  number  six  shows  another  donation  of  equal  amount, 
but  with  results  differing  greatly  from  those  given  in  form  num- 
ber five.  None  of  the  persons  benefited  had  any  occupation,  they 
were  all  a  burden  to  society,  well  or  ill;  when  restored  to  health 
none  of  them  was  capable  of  taking  up  a  portion  of  the  world's 
work,  and  by  restoring  them  to  health  the  institution  simplj  in- 
creased the  burdens  of  the  community.  In  other  words,  this 
amount  of  money  resulted  in  no  actual  good;  in  fact,  it  is  likely 
that  in  a  way  the  natural  law  of  the  survival  of  the  fittesl  was 
artificially  tampered  with  by  the  expenditure  of  this  money. 

It  may  be  said  that  this  is  an  uncharitable  view  of  the  case, 
but  it  seems  reasonable  to  demand  that  some  good  should  come 
from  all  charitable  funds.  Were  all  such  cases  utilized  as  clinical 
material  for  demonstrations  before  classes  of  students,  or  to  be 
operated  upon  by  them  in  order  thai  they  should  become  competent 
to  treat  properly  the  useful  members  of  society  after  completing 


560  HOSPITAL  FINANCES 

their  medical  training,  then  the  amount  expended  would  result  in 
sufficient  benefit  to  society  to  make  it  worth  while. 

hi  the  ease  of  individual  contributions  a  like  statemeni  should 
be  rendered.  It  is  most  detrimental  to  the  finances  of  a  hospital 
to  place  all  of  the  contributions  to  the  institution  into  a  general 
fund,  and  to  use  them  promiscuously  without  accounting  to  any 
one  for  the  direct  application  of  any  definite  part  of  the  money. 
Such  a  course  will  prevent  person-  who  are  no!  personally  inter- 
ested in  the  institution  from  filling  charity  beds  with  perverts,  de- 
generates and  habitual  malingerers  whose  profession  ii  is  to  spend 
much  of  their  time  in  a  hospital  where  they  have  Keen  placed 
through  the  influence  of  some  person  who  is  more  charitable  than 
wise.  Many  institutions  at  the  present  time  have  a  considerable 
portion  of  their  resources  diverted  in  this  manner.  Were  a  defi- 
nite report  made  to  each  contributor  indicating  the  results  bis 
contribution  has  accomplished,  it  is  likely  that  much  01  this  money 
would  go  toward  restoring  useful  members  of  society  to  a  condi- 
tion which  would  enable  them  to  earn  the  support  of  themselves 
and  their  families. 

This  especial  feature  is  applicable  to  the  conduct  of  hospitals 
under  the  management  of  church  or  charitable  organizations  in 
which  a  portion  of  the  institution  is  given  to  the  eare  of  private 
patients,  hut  does  not  apply  to  State,  county  or  city  institutions, 
nor  to  large  hospitals  which  are  entirely  given  up  to  the  treat- 
ment of  charity  patients,  because  in  these  institutions  the  general 
report  will  have  the  same  effect  a-  the  special  reports  in  hospitals 
which  are  conducted  partly  for  the  care  of  charity  and  partly  for 
tli*-  care  of  private  patients.  The  same  ma\  ho  said  of  Institutions 
conducted  by  various  industrial  corporations,  each  corporation 
contributing  sums  in  proportion  to  the  number  of  employes  that 
are  benefited  by  a  given  hospital.  The  plan  is  advisable  in  hos- 
pitals conducted  by  fraternal  insurance  societies  lor  the  benefit  of 
go  earners,  for  then  in  each  instance  an  interested  person  can 
determine  the  extent  to  which  the  institution  has  benefited  its 
members. 

BOOKKEEPING  PROPER. 

The  pasl  lev  years  have  developed  a  large  number  of  sys- 
tems of  bookkeeping  in  which  the  card  index  plan  is  the  leading 
feature.  The  number  of  hooks  has  necessarily  been  reduced  and 
the  amount  of  labor  has  been  correspondingly  decreased.  By  the 
introduction  of  ledgers  with  removable  pages,  the  bulk  of  the 
ledger  has  been  greatly  curtailed  and  the  entire  system  very  much 
simplified.    Any  one  of  a  number  of  these  modern  forms  will  serve 


HOSPITAL  FINANCES  561 

the  purpose  adequately.  Most  of  these  systems  have  been  pat- 
ented, and  it  would  scarcely  be  proper  to  introduce  the  name  of 
any  one  of  them,  but  in  connection  with  every  institution  there  is 
some  one  who  employs  these  modern  forms  of  bookkeeping  in  his 
private  business,  and  it  will  be  an  easy  matter  to  make  the  neces 
sary  changes  which  are  indicated  to  render  one  of  these  systems 
perfectly  applicable  to  the  needs  of  a  hospital;  moreover,  the 
proprietors  of  these  various  systems  are  willing  to  furnish  ex- 
perts to  assist  in  the  adjustment  of  a  system  to  the  conditions  in 
any  given  case. 

FINANCIAL  SUPPORT  OF  HOSPITALS  CONDUCTED    BY 
CHUECH  OR  CHARITABLE  ORGANIZATIONS. 

The  source  of  the  financial  support  will  depend  largely  or 
entirely  upon  the  character  of  the  institution,  which,  if  a  public 
institution,  must  necessarily  depend  upon  the  State,  county  or  < •  i t  \ 
the  money  being  collected  in  the  form  of  taxes.  Under  such  cir- 
cumstances the  Superintendent  should  prepare  a  requisition  to 
present  to  the  proper  authorities.  This  requisition  should  sel 
forth  the  amount  of  money  needed  for  the  maintenance  of  the  insti- 
tution, for  repairs,  and  for  additional  buildings  in  case  these  are 
required.  The  sum  set  aside  for  the  maintenance  of  the  institution 
for  the  ensuing  year  should  be  determined  by  a  legislative  body, 
the  State,  county  or  city,  and  the  expenditure  should  be  regulated 
so  as  to  remain  reasonably  within  the  limits  of  the  annual  appro- 
priation, except  in  case  of  epidemics  and  various  catastrophies 
which  might  justify  the  Superintendent  of  the  hospital  in  going 
beyond  the  appropriation  for  the  year. 

In  hospitals  conducted  by  philanthropic  or  church  societies 
there  are  three  regular  sources  of  financial  support.  First,  there 
is  usually  a  membership  fee,  which  may  be  applied  to  a  general 
fund  for  the  care  of  charity  patients,  or  it  may  he  applied  to  a 
fund  provided  for  the  care  of  the  sick  members  of  the  association. 
Second,  these  institutions  usually  have  n  portion  of  the  building 
set  aside  for  the  care  of  private  patients,  and  the  income  paid  by 
these  patients  for  hospital  care  provides  ;i  considerable  portion 
of  the  money  used  in  conducting  the  institution.  The  third  source 
comes  through  voluntary  contributions  without  reference  to  mem- 
bership. 

KINDS  PROYIDKI)  FROM   MEMBERSHIP  FKFS. 

The  amount  of  energy  that  iias  to  be  expended  in  securing  the 
annual   membership  fee  is  usually    considerable  when   compared 


562 


HOSPITAL   FIX  AN 


with  the  financial  results.    It  is  doubtful  if  any  institution  in  this 
country  ever  flourished  under  this  system  alone. 

In  organizing  a  hospital  in  which  the  membership  fee  is  ex- 
pected to  defray  a  considerable  portion  of  the  current  expenses, 
the  following  form  lias  been  found  to  be  the  leasi  objectionable. 

Ko^-^l, . — — 

G  rfdAUi/i    


BaL.    wiu 


U. 


n 


iitu 


cLlaX 


lfaJ 


jAaI 


3£ 


X~~ 


ir-t.  iWU^^jLtAA^k,,./ 


.at       d... 


&L 


"^V*v  I  V-t^J  . 


&Uc* 


h 


n 


ii 


Um^   -i^vy 


The  amount  of  the  annual  membership  fee  should  be  suffi- 
cient to  produce  in  the  aggregate  a  considerable  fund.  Experience 
Has  shown  that  it  is  quite  as  easy  to  secure  memberships  with  the 
annual  fee  of  ten  dollars  as  it  is  with  a  smaller  fee.  A  record  of 
the  members  and  their  payments  should  be  kept  in  the  card  index, 
and  also  in  the  cash  book  of  the  association.  The  card  index  is 
arranged  according  to  the  months  of  the  year,  the  cards  being 
grouped  during  the  months  in  which  the  annual  contribution  be- 
comes due  in  each  individual  case.  When  the  card  of  the  person 
whose  name  it  bears  indicates  that  the  annual  fee  becomes  due 
the  following  month,  a  letter  is  sent  to  such  member  stating  the 
date  on  which  his  annual  contribution  becomes  due.  This  letter 
should  inclose  a  blank  check  payable  to  the  treasurer  of  the  asso- 
ciation. It  should  bear  on  its  face  the  amount  of  the  annual  fee, 
and  the  date  on  which  it  becomes  due.  A  blank  is  left  for  the 
member  in  question  to  fill  in  with  the  name  of  the  bank  on  which 
the  check  is  to  he  drawn.  The  letter  should  also  contain  an  en- 
velope addressed  to  the  treasurer  of  the  association. 

Many  contributors  who  might  lay  aside  a  simple  announce- 
ment of  the  fact  that  their  contribution  is  due  will  till  out  and  mail 
this  check  at  one-,  because  of  the  convenience  of  the  system.  Some 
of  the  members  will  prefer  to  substitute  their  own  checks  for 
those  that  have  been  sent  to  them.     The  cards  of  those  who  do  not 


HOSPITAL  FINANCES  ~><>:> 

remit  should  be  kept  in  a  separate  file  and  such  members  should  be 
again  reminded  of  the  fact  that  their  remittance  is  due  with  suffi- 
cient force  to  bring  results. 

The  same  system  can  be  applied  for  the  purpose  of  securing 
the  funds  to  support  a  hospital  conducted  for  the  benefit  of  wage 
earners.  In  this  case  there  will  be  greater  difficulty  in  collecting 
the  necessary  funds  unless  the  corporation  by  whom  these  wage 
earners  are  employed  has  an  arrangement  with  its  employes  ac- 
cording to  which  a  certain  portion  of  the  wages  is  deducted  each 
month,  and  transferred  to  the  hospital  fund.  The  amount  collected 
from  each  wage  earner  should  not  be  less  than  one  dollar  per 
month.  In  case  the  amount  collected  is  in  excess  of  the  necessary 
expenditure,  a  sinking  fund  should  be  established  for  the  purpose 
of  constructing  new  buildings,  and  for  use  in  case  of  some  extraor- 
dinary emergency. 

The  system  of  conducting  hospitals  after  this  plan  must  ulti- 
mately result  in  great  benefit,  because  of  the  possibility  of  obtain- 
ing treatment  and  care  for  the  sick  at  a  reasonable  expenditure  of 
money.  The  fact  that  the  individuals  who  pay  for  this  cave  will 
receive  it  for  themselves  and  their  families  makes  such  a  system 
most  praiseworthy.  At  the  present  time,  however,  this  plan  has 
not  attained  any  great  degree  of  usefulness,  and  it  will  require  the 
earnest  endeavor  of  medical  men  of  the  highest  business  and  pro- 
fessional qualities  to  develop  the  possibilities  of  this  class  of  hos- 
pitals. There  are  a  few  instances,  it  must  lie  acknowledged,  in 
which  a  remarkable  degree  of  success  has  been  achieved  by  insti- 
tutions of  this  class,  so  that  those  who  are  interested  can  have  some 
precedent  for  their  guidance. 

[NCOME  F1JOM  PRIVATE  FINDS. 

The  income  from  private  patients  depends  largely  upon  the 
medical  staff.  If  the  members  of  the  medical  staff  of  the  institu- 
tion have  a  sufficiently  large  and  profitable  practice  to  enable  them 
to  send  many  well-to-do  patients  to  the  hospital,  then  a  sufficient 
amount  of  money  can  easily  be  realized  to  defray  the  entire  inn 
ning  expenses  of  the  institution,  supplying  the  care  not  only  for 
the  private  patients,  but  also  for  the  charity  inmates. 

Inder  this  plan  it  is  necessary  to  have  three  grades  of  pa- 
tients: Those  that  pay  a  sufficient  sum  to  the  institution  for  their 
maintenance  ami  to  provide  a  profit.  These  patients  should  be 
known  as  private  patients.  The  second  class  of  patients  pay  less 
than  enough  to  defray  t he  expense  their  care  incurs  upon  the  insti 
tution;  and  these  patients  should  he  known  as  pail  charity  patients. 
The  third  class,  which  can  contribute  nothing  toward  their  support. 


564  HOSPITAL   FTXA\<  ES 

should  be  known  as  full  charity  patients.  This  plan  has  been  found 
satisfactory  in  most  communities  in  this  country  except  in  very 
large  cities.  A  hospital  obtaining  its  support  in  this  manner  fairly 
enters  the  Held  of  competition  irpon  its  own  merits. 

There  are  two  dangers  to  which  institutions  of  this  class  are 
exposed:  First,  in  their  becoming  purely  money-making  institu- 
tion.-- and  thus  losing  the  primary  object  for  which  they  are  in- 
tended; the  second  danger  may  come  from  the  selfish  tendency  of 
some  members  of  the  staff  which  will  either  result  in  financial  em- 
barrassment of  the  institution,  or  it  will  unfairly  burden  the  more 
generous  members  of  the  staff. 

There  are  in  every  community  a  number  of  patients  requiring 
hospital  care  who  have  hut  a  small  amount  of  money  at  command. 
If  these  patients  are  sent  to  hospitals  which  obtain  their  financial 
support  in  the  manner  just  described,  it  is  important  to  the  exist- 
ence of  the  institution  that  they  be  sent  early  before  their  limited 
means  is  exhausted  so  that  they  will  be  able  to  pay  in  part  or  in 
whole  for  the  care  they  receive.  This  must  necessarily  result  in  a 
certain  degree  of  hardship  to  the  attending  physician,  but  under 
existing  circumstances  he  will  have  to  make  this  sacrifice  in  order 
to  preserve  the  institution  in  which  he  is  interested. 

SELECTION  OF  CHARITY  PATIENTS. 

At  this  point  it  becom'es  necessary  to  digress  in  order  to  estab- 
lish a  basis  for  the  above  classification.  The  first  class  will  be  seif- 
selected  patients  who  are  financially  able  to  pay  for  their  care,  and 
who  will  choose  rooms  that  will  give  them  the  comforts  ami  even 
luxuries  they  would  desire  were  they  selecting  lodgings  at  a  hotel. 
The  amount  charged  for  such  accommodations  varies  with  the 
size  and  location  of  the  rooms.  An  additional  charge  is  made  in 
case  the  patient  desires  a  special  aurse  who  will  give  all  of  her 
time  and  attention  to  ibis  particular  patient.  These  charges  must 
aecessarily  varv  with  the  conditions  under  which  the  hospital  ex- 
ists, precisely  as  the  prices  of  rooms  in  hotels  vary  in  different 
cities.  Iii  the  smaller  cities  the  price  should  be  from  two  to  four 
dollars  a  day,  with  an  additional  charge  of  from  one  and  a  half  to 
three  dollars  per  day  for  a  special  nurse.  In  a  tew  of  the  larger 
cities  i:i  the  country  it  i^  reasonable  to  charge  from  three  to  seven 
dollars  per  day,  and  from  three  to  five  dollars  per  day  for  special 
nurses: 

Tic-  second  class  of  patients  should  com]. rise  patients  who 
have  small  personal  incomes,  or  whose  hospital  expenses  are  de- 
frayed by  friends  or  relatives.  They  should  pay  from  one  to  two 
dollars  per  day  for  their  hospital  care. 


HOSPITAL  FINANCES  565 

The  third  class  of  patients— those  unable  to  pay  at  all — should 
be  very  carefully  selected,  because  it  is  in  the  selection  of  this 
class  that  disastrous  errors  in  administration  are  most  likely  to 
occur. 

There  are  several  important  considerations  governing  the  ad- 
mission of  this  latter  class,  quite  irrespective  of  the  so-called 
charitable  character  of  the  hospital. 

In  the  first  place,  such  patients  should  be  selected  with  refer- 
ence to  the  curability  of  the  malady  from  which  they  are  sufferings 
second,  with  regard  to  the  fact  whether  or  not  they  have  been  in 
some  capacity  useful  members  of  society;  and  third,  whether  they 
are  at  the  time  unable  personally  to  pay  for  their  hospital  care, 
or  have  friends  or  relatives  able  or  willing  to  pay  for  it  for  them, 
or  whether  or  not  they  belong  to  any  association  which  protects 
them  in  case  of  .sickness  by  paying  for  such  care. 

It  is  of  the  greatest  importance  in  the  conduct  of  hospitals, 
except  in  those  that  are  conducted  for  incurable  patients,  tint  only 
those  patients  are  admitted  whose  diseases  can  be  classified  as 
curable.  If  this  precaution  is  not  taken,  the  hospital  will  soon  be 
filled  with  patients  who  are  benefited  only  because  of  the  fact  that 
they  receive  their  board  and  lodging  for  an  indefinite  period  of 
time.  It  must  be  remembered  that  the  hospital  is  equipped,  nol  as 
a  boarding  house,  but  as  an  institution  for  the  cure  of  disease. 
If  it  is  filled  with  incurables,  the  very  object  of  its  existence  is  at 
once  abolished  and  it  becomes  useless  as  a  hospital  proper. 

SELF-MAINTENANCE. 

It  is,  of  course,  important  to  the  success  of  a  hospital  to  have 
every  person  who  can  possibly  do  so  pay  tor  his  cure,  either  direct- 
ly by  himself,  or  through  his  friends  or  some  association.  Tins 
condition  of  independence  makes  the  patients  far  more  apprecia- 
tive of  what  is  done  for  them  both  a1  the  time  they  arc  in  the 
hospital,  as  well  as  after  they  return  to  their  homes.  Institutions 
in  which  the  greater  portion  of  the  patients  do  pay  lor  their  care 
are  certain  of  much  more  prosperity  than  their  competitors  who 
supply  free  maintenance  to  patients  who  could  provide  foi  their 
own  support  if  they  hut  chose  to  do  so.  This  natural  condition 
contains  direct  application  of  a  principle  which  is  ver\  old.  The 
patient  who  is  given  free  service  when  he  is  capable  of  self-support 
sacrifices  his  self-respect  and  looks  upon  what  he  receives  in  the 
way  one  looks  upon  what  has  of  late  Ween  described  as  "graft." 
It  is  unnatural  that  any  one  receiving  this  malt  should  respeel 
either  himself  or  those  who  dispense  it,  consequently  if  one  had  no 
object  in  mind  except  the  desire  el'  sel  l-preservat  ion.  it  would  still 


566  EOSPITAL  FINANCES  , 

be  important  to  employ  as  far  as  possible  the  principle  of  making 
patients  self-supporting  as  regards  their  hospital  maintenance. 

POVERTY. 

The  greatesl  abuse  in  the  financial  management  of  hospitals 
conies  from  the  fault v  selection  of  charity  patients.  Great  sums 
of  money  are  annually  expended  for  the  care  in  hospitals  of  pa- 
tients who  are  not  morally  entitled  thereto.  All  hospital  authori- 
ties can  recall  many  instances  of  patients  who  have  abused  this 
privilege.  To  avoid  this,  some  institutions  have  established  print- 
ed forms,  which  are  filled  out  in  accordance  with  the  statement  of 
the  patient  regarding  his  name,  address,  occupation,  age,  duration 
of  illness,  and  his  financial  standing.  The  patient  also  states 
directly  that  he  is  entirely  incapable  of  paying  for  his  hospital 
care.  He  signs  this  statement,  which  is  also  signed  and  witnessed 
by  the  official  of  the  hospital  who  receives  it.  If  the  patient  has 
made  false  representations  he  is  liable  to  punishment  for  obtain- 
ing money  under  false  pretenses.  The  patient  should  give  as  ref- 
erence two  reliable  persons  with  whom  the  hospital  authorities  can 
communicate.  If  there  is  anything  suspicious  in  the  reports  of 
these  references,  the  matter  should  be  examined  and  the  patient 
prosecuted  so  that  the  institution  may  obtain  credit  for  enforcing 
honest  dealing.  It  will  never  be  possible  to  entirely  prevent  mis- 
takes in  this  direction,  but  the  amount  of  abuse  of  free  hospital 
privileges  can  be  reduced  to  a  minimum. 

It  may  be  worth  while  to  use  a  few  authentic  illustrations  to 
show  the  extent  to  which  such  abuse  may  be  employed.  A  person 
appearing  like  a  farm  laborer  brought  his  son  to  the  hospital,  stat- 
ing that  he  had  been  referred  by  a  neighbor  who  had  praised  the 
surgical  treatment  ami  the  kindness  he  had  received  from  those 
connected  with  the  institution.  The  neighbor  had  received  his 
treatment  and  care  free  of  charge,  which  was  a  further  reason  why 
the  person  under  consideration  desired  to  bring  his  son  to  the  hos- 
pital. Investigation  showed  that  the  father  of  patient  number  two 
owned  three  thousand  acres  of  land  in  a  vicinity  where  land  sold 
for  a  little  over  one  hundred  dollars  per  acre.  This  item  of  his 
estate  alone  equaled  more  than  a  quarter  of  a  million  dollars,  and 
yet  the  man  and  his  son  had  the  appearance  of  poor  farmers.  If 
this  case  had  not  been  investigated  the  hospital  authorities  would 
undoubtedly  have  felt  that  they  had  bestowed  their  charity 
worthily. 

Another  instance  occurred  in  which  a  married  woman  had 
received  free  care  at  one  of  the  well-known  hospitals.     When  she 


H0SP1TAI.  PINAN(  ES  •JU' 


was  ready  to  leave  the  hospital  her  husband  came  to  take  her  home. 
He  discovered  that  no  one  had  taken  the  trouble  to  investigate  his 
financial  condition,  and  so  invested  the  sum  of  three  hundred  dol- 
lars in  an  ornament  for  his  wife,  which  he  foolishly  presented  to 
her  before  they  left  the  hospital,  thus  unintentionally     bringing: 
about  an  investigation  which  proved  him  amply  able  to  pay  lib- 
erally for  the  care  his  wife  had  been  given.    Such  instances  could 
be  enumerated  indefinitely.    Occasionally  it  happens  that  patients 
who  accept  such  free  treatment  are  entirely  ignorant  of  the  wrong 
they  have  done  to  the  institution,  to  the  community  and  to  them- 
selves, for  the  reason  that  they  have  not  given  the  matter  the 
slightest  thought.     On  the  other  hand,  hospital  authorities  are 
often  so  anxious  to  fill  the  institution  with  patients  that  they  do 
not  take  the  trouble  to  institute  the  necessary  investigation  of  the 
financial  condition  of  any  patient  who  may  apply  for  hospital  care. 
It  also  happens  that  members  of  the  medical  staff  are  often  over- 
zealous  in  obtaining  interesting  cases  for  their  various  depart- 
ments, and  for  this  reason  they  fill  their  wards  with  undeserving 
free  patients.     Ultimately  this  must  result  in  an  endless  amount 
of  harm  to  every  one  concerned. 

VOLUNTARY  CONTRIBUTION  S. 
In  the  great  cities  and  in  the  older  small  ones  it  is  not  neces- 
sary to  obtain  funds  for  miaintaining  the  hospital  through  member- 
ship fees,  because  the  greater  portion  of  the  money  can  be  obtained 
from  contributions  by  philanthropic  persons.  Experience  has 
shown,  however,  that  unless  it  is  possible  to  secure  large  donations 
from  single  individuals,  it  is  much  better  for  the  continued  pros- 
perity of  the  institution  to  obtain  its  financial  support  in  the  man- 
ner indicated  above. 

It  is  important  to  make  a  definite  distinction  between  the 
money  which  has  been  contributed  for  the  purpose  of  defraying 
current  expenses  and  that  which  lias  been  given  expressly  for  the 
purpose  of  establishing  endowments.  It  may  be  as  much  of  a  hard* 
ship  for  a  hospital  to  exist  without  consuming  any  portion  of  its 
endowment  fund,  as  it  sometimes  is  for  an  individual  with  a  defi- 
nite income  to  live  within  his  means.  A  lack  of  appreciation  in 
either  case  in nst  result  in  financial  ruin. 

It  is  proper  in  some  instances  to  utilize  money  in  the  endow- 
ment fund  for  the  purpose  of  erecting  buildings,  but  this  is  the 
case  only  when  a  sufficient  income  from  other  sources  is  ;if  hand  lo 
provide  for  the  current  expenses  of  the  institution.  In  su  ih  a  case 
the  use  which  is  made  of  the  endowment  fund  would  correspond 
to  the  borrowing  of  money  for  construction  purposes.     The  inter- 


olis  HOSPITAL  FINANCES 

esl  on  the  money  representing  the  amount  of  the  endowment  should 
be  paid  into  the  maintenance  fund  from  whatever  source  the  inter 
esl  "ii  the  endowment  may  have  been  provided  for.  In  this  man- 
ner the  income  will  actually  serve  the  purpose  for  which  it  was 
intended.  Unless  an  endowment  is  eared  for  precisely  in  the  man- 
ner in  which  an  estate  held  in  trust  should  be  managed,  the  result 
musl  necessarily  be  as* disastrous  to  the  finances  of  the  institution 
as  would  be  careless  administration  of  an  estate..  There  is,  how- 
ever, this  difference,  ordinarily  the  funds  of  a  spendthrift  son  of  a 
wealthy  father  cannot  readily  be  replenished  after  the  estate  has 
been  squandered,  while  in  the  management  of  hospital  endowments 
new  endowments  may  he  secured  to  replenish  the  empty  treasury 
after  the  same  principle  has  been  applied. 

The  bequests  in  favor  of  hospitals  always  increase  with  the 
age  of  the  institution,  if  the  latter  provides  good  care  for  the  pa- 
tients. Because  of  this  fact  even  badly  managed  hospitals  may  be 
fairly  prosperous,  but  it  can  easily  be  seen  thai  with  the  elimina- 
tion of  these  faulty  elements  in  the  financial  management,  the 
prosperity  must  be  vastly  increased.  It  has  been  demonstrated  in 
a  number  of  instances  that  these  latter  institutions  have  been  able 
to  accomplish  a  much  greater  amount  of  actual  charity  than  other 
institutions  which  have  received  many  times  as  much  money  in  the 
form  of  donations  or  bequests.  A  study  of  these  particular  in- 
stances -hows  that  in  every  case  there  is  at  least  one  member  of 
the  Board  of  Trustees  who  has  been  unusually  successful  as  a 
business  man.  and  who  insists  upon  the  use  of  the  same  sterling 
principles  in  the  management  of  the  hospital  that  have  determined 
his  prosperity  in  his  business  enterprises. 

OTHEB  METHODS  OF  APPLYING  ENDOWMENT  FUNDS. 

In  the  older  hospitals  in  which  the  entire  plant  has  been  con- 
structed there  is,  of  course,  no  occasion  to  loan  any  portion  of 
the  endowmenl  fund  to  the  fund  for  buildings  and  equipment.  In 
these  institutions  it  is  of  the  greatest  importance  to  arrange  mat- 
ters so  that  only  the  income  from  the  endowments  is  used  foi  cur- 
rent expenses.  Thisjnay  seem  like  a  hardship  to  institutions  with 
a  large  endowment  fund  and  a  small  appropriation  for  current 
expenses,  hut  if  the  endowment  itself  is  drawn  upon  for  expense-, 
it  will  not  take  long  to  cripple  the  finances  of  the  undertaking,  [f 
more  than  the  income  is  consumed  each  year,  the  result  must  he 
identical  with  that  which  befalls  any  other  enterprise  in  case  the 
managers  should  live  beyond  their  mean-. 

In  order  to  have  a  definite  income  the  endowment  funds  should 
be   invested   in   absolutely    safe   securities   which   will    he   sure  to 


HOSPITAL  FINANCES  569 

yield  a  certain  fixed  sum  for  an  indefinite  period.  Such  securities 
will  not,  of  course,  bring-  so  large  an  income  as  might  be  obtained 
were  the  money  invested  Less  securely,  and  less  permanently,  Inn 
it  is  easier  to  maintain  the  prosperity  of  an  institution  with  a  mod- 
erate income  that  can  be  depended  upon  than  with  a  larger  and 
uncertain  one.  Experience  has  shown  that  institutions  which  live 
strictly  upon  their  legitimate  incomes  find  it  much  easier  to  prac- 
tice economy  in  management  than  do  the  institutions  which  con- 
sume for  current  expenses  the  money  which  is  intended  for  en 
dowment  funds.  This  is  illustrated  most  forcibly  in  a  study  of 
the  finances  of  various  hospitals  with  a  view  to  determining  in 
each  instance  the  items  which  have  consumed  most  of  the  means. 

In  the  institutions  which  live  within  their  means,  such  items 
as  milk,  meats,  linen  and  surgical  dressings  cost  much,  relatively, 
while  drugs,  surgical  instruments,  office  expenses  and  luxuries  con- 
sume relatively  little. 

In  hospitals  which  live  beyond  their  means,  quite  tiie  opposite 
is  true.  This  can  be  explained  in  the  following  manner:  The 
institutions  of  the  first  group  expend  their  money  for  things  which 
serve  to  benefit  the  patients,  and  thus  secure  a  reputation  for  the 
institution  in  the  proper  direction.  Those  of  the  second  group 
follow  the  whims  of  the  persons  in  every  department,  each  one 
knowing  that  the  amount  of  money  expended  is  entirely  immaterial 
to  him  personally;  as  an  instance,  all  kinds  of  untried  and  expen 
sive  instruments  and  drugs  are  ordered  and  never  used,  which,  of 
course,  greatly  increase  the  total  amount  of  money  expended.  As 
a  matter  of  observation,  it  may  be  stated  that  the  hospitals  of  the 
first  group  always  compare  favorably,  in  every  way,  with  those  of 
the  second  group. 

ACTUAL  COST  OF  CONDUCTING  HOSPITALS. 

It  is  customary  to  determine  the  cost  of  maintaining  hospitals 
by  taking  the  expense  during  the  entire  year  and  dividing  it  by 
the  number  of  days  of  treatment  which  has  been  given  to  patients 
during  the  year.  In  case  the  hospital  is  divided  into  private  room-. 
and  private  genera]  wards,  an  attempt  is  sometimes  made  to  deter- 
mine the  relative  cost  of  maintenance  of  each  of  these  groups.  To 
this  should  he  added  the  interest  of  the  amount  expended  in  con- 
structing and  furnishing  the  hospital. 

There    is   a    marked    difference   as    regards    the    daily    eosi    of 
maintenance  in  different  institutions     The  cost  varies  from  sixty 
seven  cents  to  two  dollars  and  eight \  seven  c<  ats  per  daw  accord- 
ing to  the  reports  of  the  various  American  hospitals.    There  are  a 
few  of  the  best  managed  State  hospitals  in  this  country  in  which 


570  HOSPITAL  FINANCES 

the  maintenance  per  day  costs  very  much  less  than  the  minimum 
figure  ({noted,  but  in  these  institutions  a  number  of  important  items 
of  expense,  such  as  milk  and  cream,  poultry  and  eggs,  beef,  mutton 
and  vegetables,  are  produced  on  large  farms  connected  with  the 
hospital,  so  that  a  fair  comparison  cannot  be  established.  It  will 
consequently  be  best  to  take  the  sums  of  sixty-seven  cents,  and 
two  dollars  and  eighty-seven  cents  as  the  minimum  and  maximum 
expense  per  day  in  hospitals,  situated  under  usual  conditions.  To 
this  must  be  added  the  interest  of  the  money  expended  in  con- 
structing and  furnishing  the  hospital.  Here  again  we  take  the 
maximum  and  minimum  amounts,  which  have  been  shown  in  a 
previous  chapter  <3f  this  work  to  vary  from  one  thousand  to  ten 
thousand  dollars  per  bed.  In  case  the  hospital  has  cost  one  thou- 
sand dollars  per  patient,  the  interest  for  the  year  will  amount  to 
forty  dollars,  or  a  little  more  than  ten  cents  per  patient  per  day. 
In  case  it  has  co/t  ten  thousand  dollars  per  patient  to  build  and 
equip  the  hospital,  the  interest  will  amount  to  four  hundred  dollars 
a  year  for  each  patient,  which  is  a  little  more  than  one  dollar  and 
nine  cents  per  day.  Adding  these  sums  to  the  daily  expense  of 
maintenance  will  give  the  astonishing  results  of  approximately  one 
dollar  per  day  in  the  one  instance,  and  in  the  other  nearly  four 
times  that  amount.  Singularly  enough,  a  careful  investigation  of 
the  care  given  to  patients  in  these  two  classes  of  hospitals  often 
demonstrates  that  in  the  hospital  spending  the  smaller  sum  it  far 
excels  that  given  in  institutions  expending  the  larger  amount,  thus 
proving  the  fact  that  the  difference  is  the  result  of  waste  in  the  one 
instance,  and  economy  in  the  other. 

A  reasonable  sum  per  day  in  hospitals  caring  for  all  its  pa- 
tients in  large  wards  should  vary  from  one  dollar  to  one  dollar 
ami  twenty-five  cents.  In  hospitals  in  which  all  the  patients  are 
cared  for  in  private  rooms,  the  cost  should  vary  from  two  dollars 
to  two  dollars  ami  fifty  cents  per  day.  If  a  larger  sum  than  this 
is  expended  there  is  invariably  either  unnecessary  waste  or  undue 
luxury.  This,  of  course,  does  not  apply  to  the  very  beautifully 
appointed  hospitals  which  are  conducted  by  their  owners  as  fads. 
Any  amount  of  money  can  be  paid  for  luxuries  in  such  hospitals 
with  perfect  propriety,  precisely  as  one  could  properly  expend 
any  amount  of  money  in  managing  a  private  mansion. 

FINANCING  PRIVATE  HOSPITALS. 

In  financing  private  hospitals  it  is  necessary  to  organize  in 
the  same  manner  as  in  other  enterprises.  Provision  must  be  made 
for  construction  and  equipment,  and  for  at  least  three-fourths  of 


HOSPITAL  1'IXAXl  ES  °'  - 

the  amount  required  for  maintenance  during  the  first  year,  one- 
half  of  the  amount  required  for  the  second,  and  one-fourth  for  the 
third  year.  In  a  few  rare  instances  private  hospitals  have  paid 
their  running  expenses  during  the  first  year,  and  have  yielded  a 
profit  after  that,  but  this  is  the  exception. 

It  is  probably  best  to  capitalize  the  undertaking  to  one-naJi 
the  valuation  of  the  land,  buildings  and  equipment,  and  to  provide 
for  the  issuing  of  bonds  for  the  remaining  half.     It  is,  however, 
necessary  to  add  at  least  fifty  per  cent,  to  the  estimated  cost.   For 
instance' an  institution  whose  estimated  cost  of  construction,  equip- 
ment and  maintenance  for  the  first  three  years  amounts  to  one 
hundred  thousand  dollars,  should  sell  stock  at  par  for  seventy-five 
thousand  dollars,  and  bond  at  par  for  an  equal  amount.    This  will 
leave  a  sufficient  margin  for  safety.     There  will,  of  course,  be  no 
dividends  for  at  least  five  years,  and  later,  although  the  earnings 
be  as  high  as  from  ten  to  twenty  per  cent,  on  the  entire  invest- 
ment, the  dividends  should  only  equal  the  current  interest  rate  on 
the  monev.     The  remaining  portion  of  money  should  he  used  for 
the  purpose  of  retiring  the  bonds.     These  bonds  should  be  made 
payable  in  twenty  or  thirty  years,  and  they  should  contain  a  pro- 
vision enabling  the  Trustees  of  the  hospital  to  retire  them  at  any 
interest-bearing  date  at  their  option,  by  giving  due  notice  to  the 
bondholders. 

ORGANIZING  HOSPITAL  STOCKS  AND  BONDS. 
At  the  present  time  members  of  the  medical  profession  have 
the  reputation  of  being  one  of  the  least  competent    portions   of 
society  in  the  management  of  business  affairs,  consequently  large 
investors  are  not  likely  to  purchase  stocks  and  bonds  the  proceeds 
of  which  are  intended  for  the  purpose  of  constructing  and  main- 
taining a  hospital.    It  is  consequently  necessary  tor  the  members 
of  the  medical  profession  interested  in  a  given  institution  to  pur- 
chase these  stocks  and  bonds  themselves,  or  to  place  them  with 
persona]   friends  who  may   he   interested  in   such   an    institution 
perhaps  for  the  benefit  it  would  he  in  the  community.     It  is  wise 
to  arrange  matters  so  that  each  interested  person  subscribes  for 
an  equal  amount  of  the  stocks  and  bonds.     The  portion  invested 
in  bonds  will  be  returned,  leaving  each  investor  with  just  one-halt 
of  his  investment  to  provide  for  the  contingency  of  depreciation 
of  the  property  which  may  occur  later  or  when  other  hospitals, 
more  modern,  appear  to  compete  with  the  original  on,..    Since  hos- 
pitals are  now  uniformly  built  with  fireproof  construction,  this 
element  of  competition  is  not  so  great  as  in  years  past,  -till  it  is 
well  to  take  this  precaution.     There  is  a  further  advantage  in  this 


.")(  2  HOSPITAL  FINANCES 

precaution.  Usually  the  stocks  ami  bonds  are  subscribed  for  by 
prospective  members  of  the  medical  staff,  and  should  one  of  these 
members  withdraw  after  the  institution  has  been  conducted  for  a 
number  of  years,  this  arrangement  will  make  it  much  easier  to 
dispose  of  his  portion  of  the  stock.  Were  this  proportion  in  hold- 
ings in  stocks  and.  bonds  not  maintained,  there  would  not  he 
the  same  tendency  toward  liquidating  the  indebtedness,  because 
the  stockholders  might  prefer  to  take  the  profit  of  the  institution 
in  the  form  of  dividends  instead  of  applying  it  to  the  retirement  of 
the  bonds.  In  institutions  of  this  kind  it  is  always  important  that 
the  stock  he  placed  in  friendly  hands.  By  following  the  plan  indi- 
cated above,  this  can  be  done  more  easily  than  in  any  other  way. 
dust  at  present  this  system  gives  rise  to  a  certain  anion  >t  of  abuse 
wherever  these  institutions  exist  side  by  side  with  those  that  are 
charitable  or  semi-charitable,  because  members  of  the  staff  of  these 
private  hospitals  are  often  at  the  same  time  members  of  the  staff 
of  the  two  other  institutions,  which  depend  in  part  for  the  money 
they  receive  from  patients  who  are  able  to  pay  for  their  care. 
Naturally  the  patients  who  are  aide  to  pay  a  large  fee  for  their 
hospital  care  will  he  sent  to  a  private  institution,  while  those  able 
to  pay  hut  a  slight  amount  or  nothing  will  be  sent  to  the  other  insti  • 
tutions,  thus  increasing  the  burdens  of  the  latter  beyond  that  which 
would  he  natural  under  the  conditions  existing  in  the  different 
locations.  One  can  readily  see  that  such  slight  matters  of  injus- 
tice must  occur,  and  that  they  will  he  adjusted  spontaneously  as 
the  development  of  the  institution  progresses.  It  is  not  unlikely 
that  this  development  will  occur  in  the  following  mannei  :  Institu- 
tions which  are  now  semi-chari table  wiil  establish  pavilions,  or 
different  portions  of  the  institution,  such  as  complete"  floors  in  the 
many  storied  hospitals,  will  he  given  entirely  to  the  care  of  pri- 
vate patients;  then  the  medical  staff  caring  for  patients  in  the 
portion  of  the  institution  devoted  to  charity  will  he  compelled  to 
place  their  pay  patients  in  departments  of  the  same  institutions 
which  are  devoted  to  private  patients.  On  the  other  hand.,  there 
will  he  hospitals  devoted  entirely  to  the  care  of  charity  patients, 
and  members  of  the  medical  staff  of  these  institutions  will  he  per- 
mitted to  place  their  private  patients  in  private  hospitals  con 
diu-tcd  by  corporal  ions. 

PHYSICIANS'  PEES 

In  connection  with  the  discussion  of  hospital  finances  it  seems 
proper  1<»  consider  the  subject  of  physicians'  tees. 

At  a  time  when  only  patient-  whose  poverty  compelled  them 


HOSPITAL   FINANCES  •"', 

to  ask  for  hospital  care  there  was,  of  course,  no  occasion  to  dis- 
cuss the  subject  of  physicians'  fees,  because  any  patient  who  pos- 
sessed means  with  which  to  pay  a  physician  for  his  services  would 
not  be  found  in  a  hospital.    In  the  older  cities  in  this  country  there 
are  still  many  institutions  which  date  hack  to  this  period,  and  they 
usually  have  prevented  the  attending  physician  or  surgeon  from 
accepting  remuneration  for  Ids  services  to  patients.     In  the  mean- 
time many  of  these  institutions  have  developed  into  palatial  estab- 
lishments which  are  now  occupied  not  only  by  the  poor,  but  also 
by  those  who  are  well  able  to  pay  for  any  services  they  may  re- 
ceive.    It  is  plain  that  with  the  changed  conditions  a  change  m 
these  matters  must  also  occur,  but  as  a  result  of  the  old  system 
the  poor  have  been  splendidly  housed  in  these  great  hospitals, 
while  the  wealthy  have  been  compelled  to  be  satisfied  with  the 
inefficieat  and  unsatisfactory  conditions  which  could  be  offered  to 
them  in  their  own  homesr  or,  if  they  went  to  hospitals  for  treat- 
ment, they  were  placed  in  "nursing-  homes,1 '  which  take  the  place 
of  private  hospitals  in  the  older  cities  of  this  country.     These 
usually  consist  of  old,  abandoned  dwelling  houses  in  which  the 
plumbing,  heating  and  ventilation  are  antiquated,  and  in  which 
none  of  the  modern  hospital   conditions  are  present,     Were  the 
physician  to  place  his  patient  in  the  modern  hospital,  to  which  he 
sends  his  charity  patients,  he  would  at  once  deprive  himself  of  a 
proper  remuneration  for  his  labors.     In  this  manner  the  patient 
who  pays  for  his  care  and  the  professional  skill  does  not  receive 
the  quality  to  which  he  is  entitled,  and  the  physician's  efforts  are 
greatly  increased  by  the  inconvenience  to  which  he  is  exposed  in 
treating  his  patients  under  these  unfavorable  conditions. 

It  is  likely  that  there  will   be  established  a   grading  of  pa- 
tients with  respect  to  professional  fees  into  those  who  pay   full 
fees,  those  who  pay  partial  fees,  and  those  who  are  treated  entirely 
free.     It  is  reasonable  to  expect  that  those  who  are  able  to  pay  for 
services  should  be  permitted  to  do  so,  and  that   those  to  whom  a 
regular   fee   would     prove-    to     be     burdensome   should    have  a 
smaller  fee,  one  which  will    be  quite   within   their   means.     They 
should  receive  precisely  the  same  care  as  do  patients  who  pay  a 
regular   fee.      Those   who  are  entirely   unable   to   pay    should   have 
their  medical  and  surgical  treatment   free  of  charge,  and  the  qual- 
ity of  the  treatment  should  still  be  the  same,  but  in  partial  recom- 
pense the  community  at  large  should  be  benefited  by  having  such 
cases  utilized  for  the  purpose  of  instructing  medical  student-  and 
young  practitioners,  provided  always  that    this  be  <\o\\<>  with  due 
consistency  to  the  patient. 


574  HOSPITAL  FIXANCES 

The  matter  of  fees  should  be  left  to  the  members  of  the  staff. 
If,  however,  the  members  abuse  this  privilege  they  should  be  re- 
moved, and  physicians  less  selfish  appointed  in  their  places.  The 
question  of  fees  is  one  of  the  most  difficult  to  handle  with  justice 
to  the  patient  and  to  the  physician.  It  is  usually  best  to  leave  the 
matter  entirely  with  the  physician  and  the  patient. 

No  charge  should  be  made  by  the  attending'  physician  or  sur- 
geon to  charity  patients  in  mixed  hospitals,  or  in  hospitals  devoted 
exclusively  to  the  care  of  charity  patients. 


LIST  OF  ILLUSTRATIONS. 

_  Page. 

Fig- 

r_Typical  plan  in  relation  to  sunlight IIj 

2— Typical  plan  in  relation  to  sunlight   • ".3 

3_Diagram  of  location  in  relation  to  sunlight '  [7 

4— Diagram  of  location  in  relation  to  sunlight [I° 

5_Diagram  of  location  in  relation  to  sunlight  .  .  .  • «  [9 

6— Diagram  of  location  in  relation  to  sunlight l20 

j Location  of  hospitals,  Lariboisiere UI 

8— Location  of  hospitals,  Hamhurg-Eppendorf    • '  -'-- 

9—Orientation— Shadow  diagram  of  cube 12o 

I0— Orientation— Shadow  diagram  of  cube    I27 

rI Orientation — Shadow  diagram  of  "U"  court 12t 

12— Orientation— Diagram  of  windows .  .  .  .  i  -'<  > 

j 3— Orientation— Diagram  of  illumination L3° 

i4_Orientation— Diagram  of  Illumination [3* 

15— Orientation— Sun  chart   • E32 

16— Orientation— Shadows  cast  by  typical  pavilion   *34 

I7_Orientation— Shadows  cast  by  "L"  shaped  pavilion    c35 

I8_Orientation— Shadows  cast  by  "U"  shaped  pavilion   135 

19—Orientatibn— Shadows  cast  by  "H"  shaped  pavilion   [39 

20 — Waterproofing   foundations    • .  .  .  UT 

21 — Waterproofing  foundations    ■ ' 42 

22— Furring  of  walls— Hollow  tile [44 

23— Furring  of  walls— Hollow  brick   • ... .145 

24— Furring  of  walls— Concrete  blocks [4o 

25 Furring  of  walls— Metal  lath    .  .  • [47 

26— Waterproofing  walls  and  ceiling '-bs 

27 — Chimneys,  brick-lined  ' '4'' 

28 — Chimneys,  brick-lined  and  with  stack [49 

29 — Wood  floors — Deafening    .  .  .  .  ■ [5° 

30— .Wood  floors— Deafening [5° 

3! — Wood  floors — Deafening [5] 

32— Wood  floors — Over  concrete c5] 

33 — Coves— Wood  at  floor  [52 

34— Coves—  Wood,  at  floor [52 

35 — Coves — Wood,  at  floor  • [53 

36— Coves— Wood,  at  floor ■ [54 

37 Coves — Wood,  at  floor,  incorrect  method [55 

38 — Doors ^ 


5/« 


LIST   OF    ILLUSTRATIONS 


Fig.  Page. 

3<  > — Doors • 1 56 

40 — Doors 157 

41 — Doors  and  transoms   158 

42 — Partitions  at  elevators  and  stairs 159 

43 — Partitions  at  elevators  and  stairs,  iron  • 160 

44 — Door  head  without  trim 161 

45 — Door  head  with  trim 162 

46 — Door  head,  with  trim  in  room,  square  head • 163 

47 — Door   jamb   without  trim    164 

48 — Door  jamb  with  trim 165 

49 — Base  hi'  >ck  and  door  trim : 166 

50 — Window  detail  without  trim 167 

51 — Window  detail  without  trim  splayed 168 

52 — Trim,  metal  clad   - .  .  169 

53 — Stops,  metal  clad    169 

54 — Bed  moulds,  metal  clad   • 170 

55 — Lockers,  open  mesh   170 

56 — Lockers,  metal  knockdown   ■ ■  .  .  171 

57 — Fireproof   partitions,   book   tile    • 178 

58 — Fireproof  partitions,  hollow  tile 179 

59, — Vaults • 180 

60 — Suspended  floors  without  beams 182 

61 — Suspended  floors  with  beams 182 

62 — Safe  live  loads  for  suspended  work 182 

63 — Saddles  on  roof • 183 

64 — Concrete  skylight  construction 184 

65 — Concrete  stair  construction   185 

•66 — Hollow  tile,  flat  arch  roof  • 186 

6/ — Hollow  tile,  flat  arch  floors 187 

68 — Hollow  tile,  flat  arch  floors 187 

69 — I  lollow  tile,  flat  arch  floors   187 

70 — Hollow  tile,  segmental  arch   • 188 

71 — Hollow  tile,  segmental  arch • 188 

y2 — Hollow  tile  columns  ■ .  .  188 

y^ — Hollow  tile  columns   189 

74 — I  follow   tile   columns    • 180 

75 — Hollow  tile  columns 189 

76 — Holli  >w  tile  columns   190 

yy — Hollow  tile  columns  • 190 

78 — Hollow  tile  columns  • 191 

79 — Hollow  tile  columns  reinforced 191 

80 — Hollow  tile  columns  reinforced 191 

81 — Reinforced  concrete  and  tile  floors  and  beams • 192 

82 — Rein  f<  >rced  concrete  floors  with  tile 192 

83 — Reinforced  concrete  floors  with  tile   193 

S4 — Reinforced  concrete  floors  with  tile 193 


LIST    OF    ILLUSTRATIONS  5/0 

Fig.  Page. 

85 — Reinforced  concrete  floors  with  tile ■ 194 

86 — Hollow  tile  stairs    • • 1 04 

87 — Iron   stairs    •  •  •  i(;.S 

88 — Hollow  tile  skylight  construction [96 

89 — Hollow  tile  fireprofing  of  beams • 197 

90 — Plumbing  "T"  fittings  • 202 

91 — Plumbing  connections    203 

-92 — Plumbing  main  drain  traps 203 

93 — One  pipe  soil  system   .' • 205 

94 — Two  pipe  soil  system ■ 206 

95 — Two  pipe  waste  system   ...  207 

96 — Non-syphon  traps   208 

97 — Refrigerator  waste  stack • 209 

98 — Refrigerator  waste    .  .  .  • 210 

99 — Air  chamber • 214 

loo — Air   chamber    215 

101 — Air  chamber 215 

102 — Air  chamber • 216 

103 — Gate  valve • 217 

104 — Globe  valve    218 

105 — Angle  valve 219 

to6 — Check  valve,  gravity 219 

107 — Check  valve,  swing 220 

108 — Cocks,  ground • 220 

109 — Cocks,  ground • 221 

1 10 — Cocks,   compression    22 1 

1 1 1 — Cocks,    Fuller    222 

1 12 — Cocks,    Fuller    • 222 

1 13 — Cocks,  Fuller,  low  pattern • 22$ 

1 14 — Cocks,  Fuller,  goose  neck  .  .  .- 223 

j  15 — Cocks,  self-closing 224 

1 16 — Cocks,  self-closing    224 

1 17 — Cocks,   self-closing 22^ 

1 18 — Cocks,   self-closing   • 226 

1 19 — Multiple  service  connections 22^ 

120 — Storage  tank  water  system • 22X 

1 2 1  — Filters    • 23 ] 

122 — Pressure  systems  of  water  supply • 235 

123 — Fixtures,  bath  tub  • 2$7 

124 — Fixtures,  bath  tub 238 

125 — Arrangement  of  fixtures,  plan   230 

126 — Floor  traps  for  tubs   • 240 

127 — Water  closet,   wall   type    240 

128 — Water  closet,  floor  connection 24  1 

129 — Water  closet,  floor  connection    •  • 241 

130 — Slop   sink    ■ 242 


580  LIST    OF    ILLUSTRATIONS 

Fig.  Page. 

[3] — Slop  hopper,  section   243 

132 — Slop    hopper,    elevation     ■ 244 

133 — Bath  room,  private .245 

134 — Lavatory,  wall  type • 246 

135 — Lavatory,  free  type 247 

[35A — Sink,  operating,  wall   ■ 248 

[36 — Sink,  operating,  free    241/ 

137 — Kitchen  arrangement   ■ • . 250 

[38     1  >iet  kitchen  arrangement    • 251 

[39 — Sink,   vegetable    .2^2 

140 — Sink,  pantry,  integral  • 2^3 

141  — Sink,  pantry,  copper  • 2^4 

142 — Drinking   fountain,  recess   256 

143 — Drinking    fountain,    wall 2^7 

144 — Drinking    fountain,  pedestal    • 258 

145 — I  [ydrotherapeutics,  plan  of  baths 259 

140 — Fixtures,  sitz  hath 260 

147 — Size  of  gas  pipes,  table • .  • 262 

1 48 — Size  of  gas  pipes,  table    2<)i, 

[49 — Size  of  gas  pipes,  table  for  fuel 211^ 

150 — Lathing,   nailings    266 

151 — Lathing — joints    2<)j 

152 — Lathing — plaster   on   metal    • 268 

[53 — Lathing,  plaster  on  metal 268 

154 — Metal   studs    269 

154A — Lathing  on   metal   studs    • 269 

155 — Corner  beads    270 

1  51  i — G  >rner  beads  27 1 

137    -Corner  heads   2/2 

[58  -Three  coat   work  on   metal  lath 272 

[59 — Ceiling  coves,   solid    i~^ 

160 — Ceiling  coves,  on  metal   274 

id  1  —  Flo  >r  o  ives  in  plaster • •  .274 

[62  —Electric  outlet  boxes 283 

[63 — Electric  cabinet  panel,  2  wire  285 

1 04 — Electric  cabinet   panel,  3  wire    .  .  .  • 286 

[65 — Electric  panel  boards,  2  wire 287 

Electric  pane!  boards,  3  wire   .  .  .  ■ 288 

[67    -Electric  circuit  breaker   289 

[68      Electric  cut  out  switch • 290 

[69     Electric  cut  out  switch 290 

170 — Electric  sua])  switch • .  .2()i 

171  —  Electric  push  switch    291 

172  Electric   switch    wall   case    • 292 

173 — Electric  snap  indicating  switch 202 

'74 — Electric  pendant  switch   293 


LIST    OF    ILLUSTRATIONS  58] 

Fig.  Page. 

175 — Electric  signal  system 294 

176 — Window  ventilator  panel   305 

177 — Window  ventilator,  8  in.  panel 306 

178 — Window  ventilator,  shutter  form , 306 

179 — Window  ventilator,  square 307 

180 — Window  ventilati  ir,  square    ■ 307 

181 — Window  ventilator,  square    • 308 

182 — Window   ventilator,   oblong-   for  sash    • 308 

183 — Window  ventilator,  panel 30(1 

184- — Wall  ventilator ■ 310 

185 — Wall  ventilator,  with  radiator 31] 

186 — Ventilating,  air  cleaning    318 

187 — Ventilating,  air  washing  apparatus   • 319 

188 — Ventilating,  air  washing  apparatus   321  1 

189 — Ventilating,  air  washing,  spray  head 321 

190 — Heating,  boiler,  round • 322 

191 — Heating,  boiler,  square  cast   .  .  .  ■ 323 

192 — Heating,  boiler,  upright  tubular 324 

193 — Heating,  boiler,  firebox   325 

194 — Heating  boiler,  furnace  type 32*  1 

195 — Heating,   water,  overhead  system    .  .  . 328 

196 — Heating,  water,  one  pipe  circuit    • 321) 

197 — Heating,  water,  two  pipe  system   330 

198 — Heating,   air  valve • 331 

199 — Heating,  hot  water,  air  valve   ■ 33  1 

200 — Heating — Steam,  low  pressure,  one  pipe 334 

201 — Heating,  steam,  air  valve   • 331  i 

202 — Iron,  cast  base '. 34* ) 

203 — Iron,  cast  lintels    • 340 

204 — Iron,  steel  lintels   • 34 r 

205 — Iron,  lintel  with  arch   • 342 

206 — Iron  columns,  built  up   • 343 

207 — Iron  columns,  built  up 34.4 

208 — Iron  copings  in  steel 345 

209 — Iron  box  girders 345 

210 — Iron  plate  girders 340 

2 1  1  — Iron   roof  truss 347 

212 — Roof  of  pitch  on  boards 354 

213 — Roof  flashings   • 333 

214 — Roof   flashings .^^(> 

215 — Roof   with    slate    358 

216 — Roof  of  pitch  ( m  cement   • 360 

217 — Roof  of  pitch  1  in  cement,  with  tile  1  >ver ■ 361 

218 — Metal  cornices  • 362 

219 — Metal    gutters    363 

220 — Metal   down  spouts.    304 


0°^ 


LIST    OF    ILLUSTRATIONS 


Fig.  Page. 

221 — Metal  down  spouts  • 365 

222 — Metal  ventilators  on  roof   • 366 

223 — Metal  ventilators  on  roof  -. 367 

224 — Metal  hoods  over  sterilizers   • 367 

225 — Metal  hoods  over  sterilizers    .  .  . 36& 

226 — Cove--  1 1  i  glass    ■ 375 

227— Coves  of  tile    .  .  .  • .375 

228 — Coves  of  tile    •  .  '. •  .  37' > 

229 — Coves  of  marble   ^jd 

230 — Tile,  lock  back  pattern    • ^JJ 

231 — Marble    partition     • 378 

27,2 — Glass    corners    • •  379 

232— Marble  corners   379 

27,2 — Tile  corners   • • 379 

233 — Globes  for  gas  burner    387 

234— Globes   for  gas   burner    ...  387 

235 — Globes  for  gas  burner   • 387 

236 — Globes  for  electric  light    • 388 

237 — Globes  for  electric  light 388 

238 — Globes  for  electric  light    • .  .  388 

239 — Globes  for  electric  light   . .- 389 

240 — Globes  for  electric  light    ■ .  . .' 389 

241 — Globes  for  gas  burner ^ 389 

242 — Globes  for  gas  burner ....  390 

243 — Globes  used  as  reflectors 390 

244 — Globes  used  as  reflectors    • 390 

245 — Globes  used  as  reflectors    • .  391 

246 — Globes  used  as  reflectors,  group 39] 

247 — Globes  used  as  reflectors   .  .  .  • 392 

248 — Globes  used  as  reflectors  .  .  .  ■ 392 

249 — Globes  used  as  reflectors 393 

250 — Tantalum   electric   lamp    304 

251 — Lighting  fixture   for  wards    305 

252 — Lighting  fixture  for  operating  room    • 396 

253 — Moore  tube  control    • 309 

254 — Nernst   lamp    : • 401 

255 — Nernst  lamp • 402 

-Nernst  lamp • 403 

257 — Lighting  of  operating  pavilion,  Lppendorf  Public  Hospital 404 

258— Lighting  of  operating  pavilion,  St.  George  Public  Hospital  • 405 

259— Lighting  of  operating  pavilion,  St.  George-  Public  Hospital 405 

Refrigeration,  insulation    -417 

261 — Refrigeration,  piping,  direct  expansion   418 

262      Refrigeration,  piping,  direct  expansion 418 

21  3  —Refrigeration,  brine  circulation 419 

264—  Refrigeration,    brine    circulation    .  .  ■ 4i«j 


LIST    OF    ILLUSTRATIONS  5^3 

Fig.  Pag,e- 

265— Refrigeration,  brine  circulation   • +2° 

2C6— Refrigeration,    temperatures    4-?o 

267— Kitchen  department,  model • 4-><s 

268— Laundry  department,  model   43° 

269— Laundry  department,  model   431 

2-0— Laundry   department,  gutter  plan    ■ 432 

271 — Laundry  sterilizers   ' 434 

272 — Laundry  sterilizing  machine   • 435 

273 — Laundry  washing  machine 43 

274— Laundry,  centrifugal  dryers,  elevation 43  > 

275 — Laundry,  centrifugal,  dryer  section   ■  ■  -437 

27C — Laundry,    starch   cooker    • 43 

2jy — Laundry,   drying   room    • 43 

278 — Laundry,  drying  room "  -•  ■  -439 

279 — Laundry,  mangle ■ 

28c— Laundry,  mangle,   1  phase    44 1 

281— Laundry,  mangle,  2  phase ■ 44-' 

282 — Laundry,   body   ironer    • 443 

283 — A  country  hospital  plan    44 

284 — A  country  hospital  plan   • • 449 

285 — A  country  hospital  plan    4o 

286— Lucy  Brinkley  Hospital,  Memphis,  Tenn 451 

287— Lucy  Brinkley  Hospital.  Memphis,  Tenn.   • 452 

288— Lucy  Brinkley  Hospital,  Memphis,  Tenn 453 

289— Lucy  Brinkley  Hospital,  Memphis,  Tenn 454 

290 — Hospital  for  small  town,  plan   • 45^ 

291 — Hospital  for  small  town,  elevation   • 4?" 

2c)2 — Hospital  for  small  town,  plan   . ■ 4,)- 

293— Hospital   for  small  town,  elevation   4<\3 

294 — Hospital,    Lariboisierre,    Paris    ■ 4O0 

295— Hospital,  Renkioi,  Dardanelles  ■ 4«7 

296— Hospital,  Herbert,  Woolwich   . 4°!  I 

297— Hospital,  St.  Thomas,  London  47° 

298— Hospital,   Friedrichshain,    Berlin    47- 

299 — Hospital  in  Moabit,  Berlin    • 4/5 

300—Hospital,  Johns  I  topkins,  Baltimore  • _ *76 

301— Hospital,  Stuivenberg,  Antwerp   478 

302— Hospital,  Municipal    St.    Denis,  elevation    Is" 

303— Hospital,  Municipal  St.   Denis,  plan   • 4&I 

304— Hospital,    Hamburg.    Eppendorf    • '4°3 

305— Hospital  for  contagious  diseases,  Newcastle  on-Tyne 485 

306— Hospital   at    Dessau,   plan    *°G 

307 — Hospital  at   I  >essau,  plan  • ,S' 

308— Hospital  at   Berlin,  Frederick's  ( Mdren's   Is'" 

309— 1  tospital  at   Frankfort,  ( Germany   . • 4<S|) 

310— Hospital,  Rudolph  Virchow,   Berlin,  general  plan   • 4')" 


5§4 

3ii — Hosp 

312 — iiosp 

3i3—  Hosp 
314— Hosp 
315— Hosp 
316 — I  [osp 
317-  Hosp 
318 — I  [osp 
319 — Hosp 
320 — I  [(  sp 
321  —  Hosp 
322—]  [osp 

323 1  I osp 

3-4 — I  I'  »sp 
325— I  [osp 
326 — I  [osp 
327 — Hosp 
32X — I [osp 
321; — I  losp 
330— 1  [osp 
331— Hosp 
332— Hosp 
333— Hosp 
334-  I  Cosp 
335— Hosp 
336— Hosp 
337— Hosp 
33&_ Hosp 
339— Hosp 


LIST    OF    ILLUSTRATIONS 

tal,  Rudolph   Virchow,   Berlin,  pavilion  plan    4111 

tal,  Charit) .  Berlin,  contagious  diseases ^u 

tal  for  treatment  of  contagious  diseases 493 

tal   for  treatment  of  contagious  diseases 404 

tal  For  treatment  of  contagious  diseases 495 

tal    with   corridor  on  outside    41)7 

tal.  Augustana,  Chicago   • 498 

tal,  Augustana,  Chicago   • 499 

tal,   Augustana.  Chicago .500 

tal.  "L"  shaped  typical  plan 503 

tal,  St.    Man  '>.  ( Ihicagi  1   .  .  .  ■ 505 

tal.  St.   Mary's,  Chicago   506 

tal.  St.  Mary's,  Chicago 507 

tal,   St.   Mary's,  Chicago    ' .508 

tal  for  municipality,  ward  floor  plan 509 

tal   for  municipality,  room  floor  plan   • 509 

tal   for  municipality,  administration  building    510 

tal   for  municipality,  administration  building    511 

tal  for  municipality,  dispensary  plan  512 

tal  for  municipality 513 

tal  for  municipality,  general  plan 514 

tal  for  children,  typical 518 

tal  for  children,  Philadelphia 519 

tal.   Park  Fever  I  lospital,  Condon 520 

tal  at   St.  Cloud,  .Minnesota 521 

tal  ward,  typical   plan 522 

tal  room,  typical  plan ^2^ 

tal,  operating  department,  typical  plan 524 

tal.  operating  department,  typical  plan   525 


GENERAL  INDEX. 


A 

Page. 

Absence  of  dust    .  .  .  .  , 

.  114 

Absence  of  noise    

Abundance  of  sunlight 

.,  ...  1  [6 

Accessibility  

Accessories,  laundry 

389 

Acetylene    „ 

Active  staff ' * 

Actual  cost  of  conducting  hospitals • 5°9 

...  ....   66 

Age  limit    , 

American  hospitals,  division  of  service   ■ 5  -> 

Air  chambers  (plumbing) 

Air  circulating  (refrigeration)    4I^ 

Air  filtration  and  washing 3  ' 

.  219 

Allele  valves    

Antiquity  of  hospitals 3 

Appointment,  motives  for "  3 

Appointments '  D~ 

Appointments,  results  of  favoritism  in  hospitals   5* 

Army  and  navy 

Assignment  of  patients   

Assistant  resident  surgeon,  duties  of   c 

Assistant  superintendent,  employment  of    ■ ''-' 

Authority  and  officers :  •  • 

Authority  for  large  hospital,  diagram  of  division 43 

Authority  for  moderate  sized  hospital,  diagram  of  division 43 

B 

,,  "»3 

1 >ase    

Base   blocks ■ "37' 

T.  34° 

I  >ases.  iron    

Batteries   (  bells  )    ■ '   ,' 

,       ,       ,  \  ~'0'S 

( telephones  )    

Baths,  shower   • 

Bath  stool   (hydro-therapeutic)    2  * 

I  Sath-tubs  ..• 23 

Bath  tubs   (hydro-therapeutic  )    2 

Bath-tub  traps 

T>  1  <s3 

Beams    

Beams  and  girders  in  steel  constructed  buildings   • M~ 


>  > 


JO 


586  GENERAL   INDEX 

Page. 

1  lells    296 

batteries  for   • 296 

hidct  1  hydro- therapeutics)   . .  .• 261 

Blanket  drying  closets   • 443 

Blow-off  tanks 208 

Body  ironer 441 

I  !<  tard  of  trustees  32 

I  'x  dlers   (  heating)    324 

1  !<  dting  and  riveting • 340 

I  '•'  <  >kkeeping    557 

Bookkeeping  proper 560 

I '.<  >x  and  plate  girders   (iron)    342 

I  '.ranches  and  stacks  ■  .  .  .  204 

Brass  pipe    218 

Brine  circulating  ( refrigeration)    414 

Buildings  of  hospitals  in  small  towns    448 

1  business  men  as  trustees 34 

Business  methods  in  hospital  management 41 

Butler's   pantry   sinks    254 

C 

Cabinets    (electric)     285 

Calcimine    ■ 281 

Capacity   (  refrigeration)    415 

Carpentry    • 1 50 

Cases 166 

Cast  iron  columns • 342 

Catch  basin    204 

Cement i8t 

Cement  work  not  suspended  (fireproofing)   185 

Centering  (fireproof)    183 

Chambers,  air   213 

Charity  accounts   • 557 

Check  valves    • 219 

Children,  hospitals  for ....515 

Chimneys  and  flues   1 46 

Church  hospitals yj 

Classification  of  floors • 370 

Classification   of   hospitals    21 

Classification  of  metal  paints 348,  349,  350,  351.  352 

Classification  of  wainscots    -37r 

Cocks  220,  22 1 ,  222 

Coil  opening   (heating) 326 

Columns    188 

Columns,  cast  iron   342 

wrought  iron  and  steel   342 

Composition  floors    374 

Compression    cocks    • 221 


^6o 


GENERAL   INDEX  5°7 

Page. 

175,  l8°-  l8r 

Concrete    

cost  of  construction  of • 

190 

deafening • 

fire-resisting  qualities  of   '   ^ 

105 

floors    '"  "  ...186 

sidewalks    "'.  ..185,    194 

stairs    •••••• 

and  tile  construction  methods  of 

224 
Connections,  service   ' ' 

Construction,  concrete • '     ' 

•  *  -+—  — 

Construction,    equipment  in 

Construction,  general   

general  tendencies  of '  '  '  ' 

fe  „  58 

Consulting   start    . 

Contracts 

Controlling    table    (hydro-therapeutics) 

Conveniences,  assignment  of * 

Copper •- .......  ..363 

Cornice 

Cost  of  fireproofing    ' 

Cost  of  foreign  hospitals    

•  ■  lsd 

Coves __e 

a  &  D 

Coves,  floor   

N  .  -/3 

Covers  ( plaster)    7    , 

Crematories,  garbage  and  water  heaters   J 

Cut-outs    ( electric)     ■ 

D 

'45 

Damp-proofing ^ 

Deafening,  concrete 

Deafening,  fireproofing    '  "  '  | 

Deafening  of  floors   • ' ? 

Denominational  hospitals  in  large  cities 

Development  of  hospitals j? 

Development  of  the  hospital 

Direct  expansion    (refrigeration)    ^ 4_^ 

Discipline  and  rules  governing  staff ^ 

Disinfectors  and  sterilizers  ■ ' 

Distribution  panels    (electric) 

■  ,  I55»  I57 

Doors   '. [59 

double-action    

frames   .'.159 

Double-action  doors   ^ 

1  )ownspouts   . 

Drainage  subsoil    jno 

systems    . 

systems   testing    ' 

Drains,    floor    • 


588  general  index 

Page. 

h<  »use    202,  204 

main   trap    202 

vel<  »city  <  >f  rl<  >w  in   203 

yard  and  area    204 

Drinking    fountains    255 

Drugs ■ ^32 

Dry   r<i  mis 438 

Dust    120.   122,'  123 

Dust,  absence  of  .  .  .  .• 11; 

E 

barb    American  hospitals   2=; 

Early  hospitals  in  England 18 

Electric    2^2,  394 

cabinets 285 

cut-<  >uts    : 284 

distribution  panels 286 

fu^es    286 

joints    ■ 284 

lights    292 

1  lutlet  boxes    283 

plugs    290 

wire 284 

Elevators    422 

Enamels    2~n 

Equipment  in  construction    422 

Equipment,   kitchen    428 

Estimate  cost  of  hospitals icmj 

Evolution  of  hospitals 26 

Excavations 142 

Expanded  metal  lath   2(>~ 

Expansii  n    tank    ^2 

Exterior   material 144 

K.xterue  staff,  necessity  of 8>j 

Externe,  surgical  • .  .   82 

Externes    64 

Externes,  number  of 60 

Extract*  >r   1  laundry  )    431  i 

Extravagance  in  maintenance  and  construction   12 

F 

Fallacy   of  "thick   coat"  painting    349 

Felt  for  roof    359 

Fell    roofing    ^$3 

Filters 2^1 

Final   plumbing  tests    212 

Finances  of  hospitals  in  small  towns  447 

Financial  schedules 542,  543.  544.  545,  546,  547,  548,  549,  550 

Financial    support  of   hospitals  conducted   by   church   or  charitable  or- 


GENERAL    INDEX  589 

Page. 

ganizations   561 

Financing  private  hospitals 570 

Finish,   wood    • 162 

metal   clad    162 

Finished   floors 152 

Fire  escapes    344 

Fireproof  material 175 

paints    [96 

stairs 194 

windows [95 

Wood • 1 96 

Fireproofing   173 

systems  of 180,   181 

Fire-resisting  qualities  of  concrete   [9] 

Fire,  safety  from 116 

Fittings  218 

Fixtures 23*  1 

kitchen    252 

laboratory 257 

operating  department   248 

Flashings    • 365 

Floor  coves  153,  375 

drains 203 

linoleum    37  1 

tests 183 

wood    371 

Floors 1 50,  374 

classification  of 370 

concrete   185 

deafening   of 150 

finished    .152 

and  wainscots y*i 

Fo°tI   534 

Footings    > 143 

Foundations    143 

Fountains,   drinking   255 

Freedom  from  smoke • 115 

Fresh  air  inlet   .' 204 

Fuel 53S 

Fuel  gas    264 

Fuller  cocks    222 

Funds  provided  from  membership  fees 561 

Furring ,45.    1 4S 

Fuses 2.S6 

Q 

Galvanized  iron 362 

(  Garbage  crematories  and  water  heaters 232 


590  GENERAL    INDEX 

Page. 

Gas 261,  40S 

fitting 261 

fuel • 264 

illumination 384 

piping    26  r 

Gate  valves    • 218 

Gauges  and  thermometers  (heating)   332 

General  consideration  of  hospital  plans    465 

General   construction    107 

General  supplies   529 

Girders  and  beams  in  steel  constructed  buildings 342 

Girders,  box  and  plate • 342 

Glass  floors   374 

Glass,  wire   ■  .  .  • 195 

Globes  385 

holophane 386 

Globe  valves 218 

( irade    141 

Graduate  nurses  for  hospital  work   100 

Gravel  roof 354,  359 

Grease   traps    208 

Ground  key  cocks 220 

Growth  of  hospital  work  in  America 19 

Growth  of  hospitals,  factors  that  influence 20 

Gutters    363 

H 

Hammer,  water 213 

Hardware 171 

Hard  plaster    270 

Head  of  department,  importance  in  the  selection  of 92 

Heating 323 

boilers   324 

coil-opening 326 

hot    water    329 

one  pipe  system 329.  334 

overhead  low-pressure  gravity  system   329 

piping • 332<  336 

radiation   327 

smoke  breeching 326 

steam ^33> 

systems 327 

temperatures 333,  33'  i 

thermometers  and  gauges   t,t,2 

two-pipe-  system   • 329,  334 

vacuum    2>37 

valves   331,  335 

and    ventilation    300 


GENERAL   INDEX  591 

Page. 

Holophane    globes 386 

Holophane  reflectors    3°° 

Hollow  tile    ' l8" 

Hoods   367 

Hospital  controlled  by  stock  company 4° 

Hospital  finances ' 539 

Hospital  staff  in  small  cities,  difficulties  in  organizing   9° 

two  plans  followed 91 

Hospital  staff,  organization  of  58 

Hospitals,  antiquity  of *5 

origin  of  ' 5 

early,  in  England I° 

increase  of  in  Germany J9 

growth  of,  factors  that  influence 20 

classification  of  • 2I 

army  and  navy   

earlv  American   2^ 

26 
evolution  of  

organization  of    ' 

development  of   3a 

church   * 3/ 

American,  division  of  service 5° 

in  small  towns " 444-  45/ 

location  of   44? 

position  of  buildings  in   • 445 

organization  of   447 

finances  of    ' 447 

nursing  staff  of 44/ 

buildings  of    ' 448 

recent    49 

for  children    '  •  5 x  d 

actual  cost  of  conducting 5°9 

financing  private  '  •  57° 

Hospitals,  general  construction io7 

cost  of  foreign ' I09 

estimate  cost   io9 

increased  cost x  I0 

location  of   ll1 

orientation  in  relation  to  sunlight i2A 

water  supply  for   235 

Hospital,  physicians'  fees  in 573 

development  of  the ltD 

controlled  by  stock  company   4° 

the  many-storied  contagious    484 

finances •  539 

organizing  stocks  and  bonds   S7l 

management,  study  of   T4 


592  GENERAL   INDEX 

Page. 

competition  in    13 

business  methods  in   41 

\\< irk,  gn >wth  1  »f  in  America   19 

plans,  general  consideration  of 465 

1  lot- water   heating .329 

Hours    for   reporting    • 83 

I  fouse  drain    204,  202 

I  [ydro-therapeutacs    -. 258 

bath  stool   261 

bath  tubs 261 

bidets    261 

controlling  table 260 

needle  and  shower  baths 260 

resume    261 

seat  bath   • 261 

shampoo  table    261 

I  [ygienic  lighting   408 

I 

Ice  making 415 

Illuminati<  >n   381 

Illuminating    with    gas    ■ 384 

Incandescent    mantles    385 

Income  from  private  funds 563 

Increased  cost  of  hospitals 1 10 

Increase  of  hospitals  in  Germany 19 

Inlet,  fresh  air ' 204 

Inside   painting 280 

Installation    I  water  supply)    212 

Instructions   regarding  distribution  of  hospital  operating,  and  corpora- 
tion or  other  current  expenses. — Administration  expenses 551 

[nsulation    1  refrigeration) 416 

Interior  wood  or  close-grained  wood  (painting) 27J 

1  nternes    • 64 

Internes,   number  of    ■ 60 

Introduction 105 

[ron • 184,  339 

Iron  bases 340 

Iron  box  and  plate  girders 342 

Iron,  galvanized    362 

Iron    lintels 34! 

Iron,  mill-scale  on 346 

In  in  purlins    • 344 

I  r<  >n  sewers    201 

Iron   shutters 34c 

I  r<  >n  stairs 34c 

Iron  trusses 343 


GENERAL   INDEX  ji)j 

Page. 

Irons    (laundry)    442 

Ironing  boards   442 

J 

Joints    (electric)    • 284 

Junior  physician;  duties  of • 80 

K 

Kind  of  iron  to  be  used   346 

Kitchen  equipment   428 

fixtures 252 

L 

Laboratory  fixtures 257 

Lath,   wood 266 

expanded  metal 267 

metal   267 

Lathing   266 

Laundry    430 

accessories 442 

dry    rooms    438 

machinery 434 

Power    433 

room 4  3 1 

steam   433 

tubs    255 

Lavatories   247 

Lead  pipe  2 16 

Light    • 117 

Lights,  electric   292,  394 

Lighting,  hygienic 408 

Lighting,  other  methods  of   .402 

Lighting,  vapor 397 

Linoleum    floors    371 

Lintels    ( iron ) ^41 

Loads  in  suspended  work   1  S3 

Location  of  fixtures 23*  > 

Location  of  hospitals   111 

Location  of  hospitals  in  small  towns   44^ 

Lockers    1 70,    1 . ,. » 

M 

Machinery,  laundry    4^4 

Main   drain   trap    _>o_> 

Mangles    439 

Manifolds 225 

Marble   fl<  >ors    ^74 

Masonry j  4 1 

Material,   fireproof    i~- 

for  plumbing  pipes    215 


5y4  GENERAL   INDEX 

Page. 

Matron,  duties  of   • 53 

Mechanical  discharge  systems -210 

refrigeration   4 1  3 

Medical  and  surgical  staff   54 

Medical   service,  permanent   service  desirable   • 72 

Medical  staff  and  nurses,  method  of  training •  .  .   48 

Medical  staff,  selection  of   54 

Metal   clad   doors    ' 157 

clad  finish 162 

Metal   lath    267 

Methods,  fireproofing   180,   181 

painting    280 

tile  and  concrete  construction 190 

ventilation    3°4 

Mill  scale  on  iron   • 34' > 

Mortar    19° 

Municipal  hospitals,  graded  staff  for   • .  .   89 

Municipal   hospitals,    perils   in   organization  of    89 

N 

Needle  and  shower  baths   (  hydro-therapeutic)    260 

New  walls   (  painting)    • 277 

Nipples   (gas)    264 

Wise,  absence  of   . ■ 114 

Nurses,  training  of 93 

pupil,  admission  of   96 

qualifications   for   admission    96 

term  of  service ■ 97 

arrangement  of  course  of  study 95 

arrangement  of  instruction  subjects 97,  98,  99,  100 

number  of ICO 

Nursing  staff  of  hospitals  in  small  towns   447 

0 

Officers,  appointment  of   49 

One  coat   w<  >rk    1  plaster  )    270 

One-pipe  system   (hot   water  heating)    329 

(  steam  heating)    334 

Open  grained  woodwork   (  painting)    •  .  .  .  .277 

Openings    (plaster  )    272 

Operating  department  fixtures 248 

Organizati< m   of  active   staff,  diagram    59 

Organization  of  hospitals 27 

Organizatii  n   of  hospitals   in   small  towns    447 

Organization  of  second  staff 67 

Orientation  of  buildings  and  of  streets  in  relation  to  sunlight   124 

of  hospital  buildings  in  relation  to  sunlight 124 

Organizing  hospital  stocks  and  bonds 571 


GENERAL   INDEX  595 

Page. 
Origin  of  hospitals • 15 

of   insane  asylums    16 

Ornamental  tile  roof   ■ 358 

Other  methods  of  applying  endowment  funds 568 

Other  methods  of  lighting   402 

Outlet  boxes   (electric)    ■ •  .  .  .  283 

Outlets   (gas)    264 

Outside  painting   • ■  280 

tanks    235 

(  Iverhead  low  pressure  gravity  system  (heating)    329 

P 

Paints    275 

fireproof 196 

metal,  classification  of 348.  349,  350.  35  1.  352 

Painting    275 

fallacy  of  "thick  coat"   • 349 

inside    280 

methods,   other •  280 

outside 280 

preparation  of  steel  for 346 

steel   348 

Partitions ■  164,    1  -j- 

tile   267 

Pathologist    • 65 

Patients,  assignment  of  '. ( >  1 

Patients,  assignment  of   70 

Patients,  cards  used  in  assignment  of ~^,  74.  j^ 

Pavilion  system ....    23 

in  America 24 

in  England   • 24 

in  France   24 

in  ( rermany ■ 24 

I  'ermanency   of   office    • 20 

Philanthn >pic  societies    • 33 

Physicians 1 1 . 

I  'h\  sicians'   tecs  in  hospitals   573 

Physicians'  influence  in  developmenl  <>t"  hospitab   36 

Picture  moulds    [63 

I  'ipe  shafts 226 

slots    1 S4 

Pipes 21(1.  217.  21S.  22^ 

gas    263 

material   for _»i  ^ 

size  of  gas   262 

I  'i] ling,  lint  water  heating 332 

re  frigerafo  ir    419 

steam   heating    J36 


5''r'  GENERAL    INDEX 

Page. 

Pitch   f,,r  r,)of  353.  359 

I  'laster   blocks    jjj 

hard   270 

one-c<  >at   work 270 

t  \v<  i-c<  >at  work    270 

three-coat  work .271 

wall?  or   win  id  work   previously  painted    277 

I  Mastering 266,  268 

I  lugs,    electric     290 

I  'lumbing iq8 

final   tests    212 

one  and  two-pipe  systems 204 

smoke  test    212 

1 N  -lineal  control  of  hospitals   2/ 

Political  control,  dangers  due  to   31 

vices   due  to    • 32 

1  'orches ....  166 

Position  of  buildings  in  hospitals  in  small  towns 445 

I  '<  iverty  <  >f  hospital  patients   566 

Power   298 

laundry 433 

Preparation  of  steel   for  painting   346 

Prepared  roofing 359 

Pressure   regulati  >rs    223 

Protection  (  firepn >ofing  ) 176 

J  'umps    227 

Purchasing  f<  ir  cash   • 531 

Purlins   (  iron  )    344 

Q 

Qualifications  for  special  duties 42 

R 

Radiation    ^27 

Recent   hospitals    496 

Reflectors,  holophane   • 388 

Refrigeration    411 

Refrigeration,  table  of  temperatures  for  various  f IstufFs  421 

Refrigerator  piping   419 

wastes    210 

Regulators,  pressure 223 

Resident  physician,  duties  of   80 

Resident  staff,  rules  for    78 

time  of  service    79 

officers  of  senior  grade • 70 

officers  of  junior  grade 79 

sequence  of  service 79 

Resident  staff,  management  of 88 

how  to  meet  perils   8<) 


GENERAL   INDEX  597 

Page. 

Resident  surgeon,  duties  of   81 

Resume    ( hydro-therapeutic)    • 26] 

Roof    148.    184,    188 

Roofing 353 

gravel    354 

prepared    • • 359 

tile,  slate  and  shingle   358 

ti"    ■ 35" 

waterproof   3^) 

S 
Safes  and  vaults ! 179 

Safety  from  fire 116 

Sand   (fireproofing)    181 

Saving  waste  materials    • 536 

Seat  bath   (hydro-therapeutic)    ■ 261 

Selection  of  charity  patients  .  .  • 564 

Self-closing  cocks 222 

Self-maintenance   (hospital )    565 

Service  connections    224 

Service,  dividing  periods  of   • 90 

Service,  duration  of • 57 

Service,  plan  of 57 

Setting    189 

of  iron 34< ) 

Sewerage    1 1  6 

Sewers,    iron    201 

tile   200 

Shafts,   pipe    • .  .  226 

Shampoo  tables   (hydro-therapeutic )    261 

Sheet  metal  work ■ 262 

Shower   baths    243 

Shutters,   iron    345 

Sidewalks,   cement    [85 

concrete    ■ 1  8l  i 

Signal    systems    -'03 

Sinks,  butler's  pantry   254 

kitchen    251 

slop    • 242 

vegetable  2j$ 

Size  of  pipes    • .  . .  225 

Size  of  piping  (gas)    202 

Skew  backs    [89 

Skylights    • [84,    [94,  366 

Skylight  vents   365 

Slate  and  stone  floors 374 

Slop  hoppers    -45 

sinks   • -24 2 


598  general  index 

Page. 

Sluts    189 

pipe    • 189 

Smoke  breeching 326 

freedom    from    • 115 

test   (plumbing)    212 

Soap  tank  (laundry)    437 

Si  >il  and    wastes    • 204 

Stacks  and  branches 204 

Staff,  appointment  of  • 61 

St  iff  duties    • 60 

Staff  organization,  advantages  of  66 

Staff,  selection  of 63 

Staffs   in   small  towns,  appointing  of   .  .  .  .  • 69 

Staining • 280 

Stairs   1 64,   1 85,   [94 

concrete    • ...  185 

iron    345 

Starch   a  ><  >kers    ; 437 

Starching   machines    • 438 

Steam  heating   ^^ 

'  (laundry)    .433 

Steel,  painting  of   348 

studs    (fireproofing)    • 178 

Sterilizers  and  disinfectors 426,  434 

Sterilizing  washer   (laundry)    43- 

Stone   (fireproofing)    • ...  181 

Sti  rage  tank  systems 22y 

Stoves,  ranges  and  food  heating  apparatus -428 

Studs,   steel    178 

Subsoil   drainage    • 211 

Superintendent,  duties  of 53 

Supply    (  gas )    262 

I  water  )    212.  235 

Surgical    dressings    ^j 

instruments    • z,^y 

Suspended  work  1  fireproofing  >    182 

Switches    287 

S\  stem,  adherence  to  definite   47 

Systems,  heating   • ^2j 

mechanical  discharge   210 

and  two  pipe  heating 329,  334 

one  and  two  pipe  plumbing •  .  .  204 

signal    293 

1;illk    • 235 

vacuum  cleaning   424 

wiring   • 282 


GENERAL   INDEX  599 

T 

Page. 

Tables,  gas-piping   z()2,  263 

loads  in  suspended  work ....  183 

temperatures   for  various    foodstuffs    42 1 

Tanks • 227 

blow-off 208 

expansion • 332 

outside    2?,^ 

soaP    • 437 

storage 227 

system    •    235 

Telephones   297 

batteries  for 298 

wiring   for    298 

Temperature   (heating)    333,  336 

Terrazzo,  flake  mosaic  and  composition  floors yj2 

Term  of  service 40 

Terms  of  office,  length  of ■ ^2 

Tests,  drainage  systems   • 21  r 

final  plumbing 212 

fireproofing   • .18-5 

floors   for    183 

gas    • 264 

smoke   (plumbing)    212 

The  grading  of  material  and  supplies   530 

The  many-storied  contagious  hospital 4X4 

Thermometers  and  gauges  (heating)    ^2 

Three-coat  work  (plaster)    271 

Tile   • [79,  188 

and  concrete  construction,  methods  of    190 

floor   • 373 

hollow    [87 

partitions   ■ _><  ,- 

sewers  200 

slate  and  shingle  roofs je8 

Tin  roof    jeg 

Training  schools,  organization  of 02 

Training  schools,  size  of  hospitals  requiring ()4 

Transoms •   1  <  „ , 

Traps,  bath  tub 240 

grease 208 

main  drain   202 

Trim rfM 

Trustees,   number  of   ; .    2S 

Trustees,  selection  of   • ^8 

Trusses    (iron  )    ^1 

Tubs,  laundry 255 


6(X)  GENERAL   INDEX 

Page. 

Two-coat  work    (plaster)    270 

Two-pipe  system,  hot  water  heating • .  .  .  .329 

steam   heating 334 

V 

Vacancies,  rilling  of 68 

Vacation,  length  of   83 

Vacuum  cleaning  systems   -424 

heating 337 

Valves   • 218,  219,  331,  335 

Vapor   lighting    $<.)"j 

Varnish   ■ 278 

Vaults  and  safes   179 

Vegetable  sinks   253 

Velocity  of  flow  in  drains ■ 203 

Ventilation  115.  [19,  120,  300,  304 

Vents,  skylight • 365 

Visiting  staff,  privileges  of   67 

Voluntary  contributions 567 

W 
Wainso >t  classification  37 r 

Wainscots  and  walls ... 37S 

Walls  and   wainscots    378 

Washers    (  laundry  )     • 435 

Wash  trays ■ 243 

tubs    ■ 437 

Waste  of  labor  and  material 53  r 

Wastes,  refrigerator 210 

and  soil    • 204 

Water  closets    240 

hammer    (plumbing)     213 

heaters  and  garbage  crematories   232 

(laundry)    ..  .• '..433 

Waterproof  roofing   359 

Water  supply 212,  235 

Windows km 

fireproof • 195 

Wirt'  1  electric  I    284 

glass  ■ 195 

Wiring  for  telephones 2<j<X 

s)  stems  of • 2X2 

W< « >d  finish    162 

fireproof   ... [96 

floors 1 50,   3~  1 

lath   • 266 

Wooden    door    155 

stairs    ...  164 

Wrought  iron  pipe   217 

iron   and   steel   columns    • 342 


THE  LIBRARY 
UNIVERSITY  OF  CALIFORNIA 

Santa  Barbara 


HIS  BOOK  IS  DUE  ON  THE  LAST  DATE 
STAMPED  BELOW. 


3,'68(H9242s8)9482 


"C  SOUTHERN  REGIONAL  LIBRARY  FACILITY 


D     OOO  268  223     5 


